Welcome to CardioNerds, where we bring you in-depth discussions with leading experts, case reports, and updates on the latest advancements in the world of cardiology. Tune in to expand your knowledge, sharpen your skills, and become a true CardioNerd!
404. Case Report: A Stressful Case of Cardiogenic Shock – Tufts Medical Center
Nov 18, 2024
CardioNerds (Dr. Dan Ambinder and Dr. Yoav Karpenshif – Chair of the CardioNerds Critical Care Cardiology Council) join Dr. Munim Khan, Dr. Shravani Gangidi, and Dr. Rachel Goodman from Tufts Medical Center’s general cardiology fellowship program for hot pot in China Town in Boston. They discuss a case involving a patient who presented with stress cardiomyopathy leading to cardiogenic shock. Expert commentary is provided by Dr. Michael Faulx from the Cleveland Clinic. Notes were drafted by Dr. Rachel Goodman. Audio editing by Dr. Diane Masket.
A young woman presents with de novo heart-failure cardiogenic shock requiring temporary mechanical circulatory support who is found to have basal variant takotsubo cardiomyopathy. We review the definition and natural history of takotsubo cardiomyopathy, discuss initial evaluation and echocardiographic findings, and review theories regarding pathophysiology of the clinical syndrome. We also highlight complications of takotsubo cardiomyopathy, with a focus on left ventricular outflow obstruction, cardiogenic shock, and arrythmias.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Takotsubo cardiomyopathy is defined as a reversible systolic dysfunction with wall motion abnormalities that do not follow a coronary vascular distribution.
Takotsubo cardiomyopathy is a diagnosis of exclusion; patients often undergo coronary angiography to rule out epicardial coronary artery disease given an overlap in presentation and symptoms with acute myocardial infarction.
There are multiple echocardiographic variants of takotsubo. Apical ballooning is the classic finding, but mid-ventricular, basal, and biventricular variants exist as well.
Patients with takotsubo cardiomyopathy generally recover, but there are important complications to be aware of. These include arrhythmia, left ventricular outflow tract (LVOT) obstruction related to a hyperdynamic base in the context of apical ballooning, and cardiogenic shock.
Patients with Impella devices are at risk of clot formation and stroke. Assessing the motor current can be a clue to what is happening at the level of the motor or screw.
Notes
What is Takotsubo Syndrome (TTS)?
TTS is a syndrome characterized by acute heart failure without epicardial CAD with regional wall motion abnormalities seen on echocardiography that do not correspond to a coronary artery territory (see below).1
TTS classically develops following an acute stressor—this can be an emotional or physical stressor.1
An important feature of TTS is that the systolic dysfunction is reversible. The time frame of reversibility is variable, though generally hours to weeks.2
Epidemiologically, TTS has a predilection for post-menopausal women, however anyone can develop this syndrome.1
TTS is a diagnosis of exclusion. Coronary artery disease (acute coronary syndrome, spontaneous coronary artery dissection, coronary embolus, etc) should be excluded when considering TTS. Myocarditis is on the differential diagnosis.
What are the echocardiographic findings of takotsubo cardiomyopathy?
The classic echocardiographic findings of TTS is “apical ballooning,” which is a way of descripting basal hyperkinesis with mid- and apical hypokinesis, akinesis, or dyskinesis.3
There are multiple variants of TTS. The four most common are listed below:3
(1) Apical ballooning (classic TTS)
(2) Mid-ventricular variant
(3) Basal variant
(4) Focal variant
Less common variants include the biventricular variant and the isolated right ventricular variant.3
Do patients with TTS generally have EKG changes or biomarker elevation?
Patients often have elevated troponin, though the severity wall motion abnormalities seen on TTE is generally out of proportion to the degree of troponin elevation.4
BNP/NTproBNP are typically elevated, especially early in the course.4
During the acute phase (defined as within the first 12 hours), patients may have ST elevation or depression, T wave inversions, new LBBB, or QT prolongation.4
What are complications of takotsubo cardiomyopathy?
Heart failure2
LV outflow tract obstruction—if there is an LVOT obstruction, it is important to avoid diuretics, vasodilators such as nitroglycerin, and inotropic agents.2
Cardiogenic shock.2
Atrial and ventricular arrhythmias.2
LV thrombus—this is of particular risk in patients with the classic “apical ballooning” variant of takotsubo due to apical akinesis and therefore stagnant flow.2
403. Cardio-Rheumatology: Treating Inflammation and Real-World Implementation of Therapies with Dr. Brittany Weber and Dr. Michael Garshick
Nov 14, 2024
In this episode, CardioNerds Dr. Gurleen Kaur and Dr. Akiva Rosenzveig are joined by Cardio-Rheumatology experts, Dr. Brittany Weber and Dr. Michael Garshick to discuss treating inflammation, delving into the pathophysiology behind the inflammatory hypothesis of atherosclerotic cardiovascular disease and the evolving data on anti-inflammatory therapies for reducing ASCVD risk, with insights on real-world implementation.
Show notes were drafted by. Dr. Akiva Rosenzveig.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday.Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Our understanding of the pathophysiology of atherosclerosis has undergone a few iterations from the incrustation hypothesis to the lipid hypothesis to the response-to-injury hypothesis and culminating with our current understanding of the inflammation hypothesis.
Both the adaptive and innate immune systems play instrumental roles in the pathogenesis of atherosclerosis.
After adequately controlling classic modifiable risk factors such as blood pressure, dyslipidemia, glucose intolerance, and obesity, systemic inflammation as assessed by CRP can be ascertained as CRP is associated with ~1.8-fold increased risk of cardiovascular events
Although the most common side effect of colchicine is gastrointestinal intolerance, colchicine can induce lactose intolerance, so a lactose free diet may help ameliorate colchicine-induced GI symptoms.
Anti-inflammatory therapeutics have shown promise in reducing cardiovascular risk but much more is to be learned with ongoing and future basic, translational, and clinical research.
Show notes – Treating Inflammation
What are the origins of the inflammatory hypothesis?
The first hypothesis as to the pathogenesis of atherosclerosis was the incrustation hypothesis by Carl Von Rokitansky in 1852. He suggested that atherosclerosis begins in the intima with thrombus deposition.In 1856, Rudolf Virchow suggested the lipid hypothesis whereby high levels of cholesterol in the blood lead to atherosclerosis. He observed inflammatory changes in the arterial walls associated with atherosclerotic plaque growth, called endo-arteritis chronica deformans.In 1977, Russell Ross suggested the response-to-injury hypothesis, that atherosclerosis develops from injury to the arterial wall.In the 1990’s the role of inflammation in ASCVD became more recognized. Both the adaptive and innate immune system are critical in atherosclerosis. Lipids and inflammation are synergistic in that lipid exposure is required but they translocate through damaged endothelium which occurs by way of inflammatory cytokines, namely within the NLRP3 inflammasome (IL-1, IL-6 etc.).Smooth muscle cells are also involved. They migrate to the endothelial region and secrete collagen to create the fibrous cap. They can also transform into macrophage-like cells to take up lipids and become foam cells.
T, B, and K cells are also part of this milieu. In fact, neutrophils, macrophages and monocytes make up only a small portion of the cells involved in the atherosclerotic process.
What are ways to individually optimize one’s ASCVD risk?
Ensure the patient is on appropriate antiplatelet therapy, lipid lowering therapy, blood pressure is well controlled, and the Hemoglobin A1c is well controlled. Smoking cessation is pivotal.
If the patient has an elevated Lipoprotein (a), pursue more aggressive lipid lowering therapy. Targeted therapies may become available in the future.
Assess the patient’s systemic inflammatory risk as measured by C-Reactive Protein (CRP)
What is the evidence for utilizing CRP in risk stratification?
CRP, initially termed Fraction C (discovered as a c polysaccharide component of the pneumococcal cell wall), was first discovered at Rockefeller University in the 1930’s. It was discovered to be an acute phase reactant in the 1940’s and noted to be synthesized in the liver in the 1960’s.
Although it is not causal in atherosclerosis, elevated CRP is associated with elevated rates of cardiovascular disease. This was first noted in the landmark New England Journal of Medicine study by Ridker et al that showed elevated CRP was associated with elevated cardiovascular risk and treating with anti-inflammatory medication (aspirin) lowered CRP and CV risk.
The statin trials also showed reduction in CRP levels was associated with better outcomes.
High-sensitivity CRP (hsCRP) >3 mg/L has odds ratio of ~1.8 for risk of CV disease.
Recent analyses of the PROMINENT, REDUCE-IT, and STRENGTH trials demonstrated that hsCRP was a more powerful determinant of recurrent CV events, CV death, and all-cause mortality than LDL-C.
After effectively controlling the previously stated modifiable risk factors, what therapeutic options remain in a patient with an elevated CRP?
CANTOS trial was the first proof of concept trial investigating Canakinumab (an IL-1 inhibitor) which showed a ~15% relative risk reduction in cardiovascular events
CIRT trial investigated methotrexate in patients without autoimmune disease. It was stopped early due to it being a negative trial. This emphasized the complex role inflammation plays in ASCVD, and that both patient selection and chosen anti-inflammatory therapy are important to consider for ASCVD risk reduction.
Colchicine has seen a lot of focus in this space with trials such as COLCOT, COPS, LODOCO, LODOCO 2, LODOCO MI. Overall, it appears that colchicine may be more effective in chronic stable ischemic heart disease. The CLEAR SYNERGY trial investigated colchicine in the peri-MI period and was a negative trial. However, we do not yet have the published data to further analyze it.
A review article by Potere et al (referenced below) provides a useful summary of novel therapies and upcoming trials in the inflammation in ASCVD space.
How do we approach inflammation in women?
We know that immune response differs between men and women. Women have more robust immune response to vaccines and viruses and greater innate and adaptive immune responses.
Women have slightly higher CRP than men. Studies have shown that average high sensitivity hsCRP is 1.7 for women and 1.2 for men. In the JUPITER trial, the subgroup of patients with hsCRP>7 mg/L had the highest proportion of women relative to men.
Regardless, hsCRP remains a reliable predictor of CV events in both men and women.
What are some practical considerations when starting colchicine?
It may help with adherence, if you walk patients through what to expect with the medication.
Obtain renal and liver function tests as both organs contribute to colchicine metabolism and clearance.
Obtain a thorough medication reconciliation as colchicine has some notable drug-drug interactions.
The most common side effects is GI intolerance; cytopenias are rare occurrences.
Note that colchicine can induce lactose intolerance, a potential mechanism for causing GI intolerance, so a lactose free diet may help with adherence.
What do we have to look forward to in the anti-inflammation space in CV disease?
There is still a lot to be learned and discovered in this space. Some clinical trials to look out for are the ZEUS, ARTEMIS, and HERMES trials which look at Ziltivekimab, an IL-6 inhibitor, in chronic kidney disease, acute myocardial infarction, and heart failure, respectively.
402. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #39 with Dr. Robert Mentz
Nov 13, 2024
The following question refers to Sections 7.3.3 and 7.3.6 of the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure.
The question is asked by Palisades Medical Center medicine resident & CardioNerds Academy Fellow Dr. Maryam Barkhordarian, answered first by UTSW AHFT Cardiologist & CardioNerds FIT Ambassador Dr. Natalie Tapaskar, and then by expert faculty Dr. Robert Mentz.
Dr. Mentz is associate professor of medicine and section chief for Heart Failure at Duke University, a clinical researcher at the Duke Clinical Research Institute, and editor-in-chief of the Journal of Cardiac Failure. Dr. Mentz has been a mentor for the CardioNerds Clinical Trials Network as lead principal investigator for PARAGLIDE-HF and is a series mentor for this very Decipher the Guidelines Series. For these reasons and many more, he was awarded the Master CardioNerd Award during ACC22.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Question #39
Ms. Kay Lotsa is a 48-year-old woman with a history of CKD stage 2 (baseline creatinine ~1.2 mg/dL) & type 2 diabetes mellitus. She has recently noticed progressively reduced exercise tolerance, leg swelling, and trouble lying flat. This prompted a hospital admission with a new diagnosis of decompensated heart failure. A transthoracic echocardiogram reveals LVEF of 35%. Ms. Lotsa is diuresed to euvolemia, and she is started on carvedilol 25mg BID, sacubitril/valsartan 49-51mg BID, and empagliflozin 10mg daily, which she tolerates well. Her eGFR is at her baseline of 55 mL/min/1.73 m2 and serum potassium concentration is 3.9 mEq/L. Your team is anticipating she will be discharged home in the next one to two days and wants to start spironolactone. Which of the following is most important regarding her treatment with mineralocorticoid antagonists?
A
Spironolactone is contraindicated based on her level of renal impairment and should not be started
B
Serum potassium levels and kidney function should be assessed within 1-2 weeks of starting spironolactone
C
Eplerenone confers a higher risk of gynecomastia than does spironolactone
D
The patient will likely not benefit from initiation of spironolactone if her cardiomyopathy is ischemic in origin
Answer #39
Explanation
The correct answer is B – after starting a mineralocorticoid receptor antagonist (MRA), it is important to closely monitor renal function and serum potassium levels.
MRA (also known as aldosterone antagonists or anti-mineralocorticoids) show consistent improvements in all-cause mortality, HF hospitalizations, and SCD across a wide range of patients with HFrEF.
The RALES trial of spironolactone vs. placebo in highly symptomatic HFrEF (LVEF ≤ 35%, NYHA III-IV), trial of eplerenone vs placebo post-MI in patients with LVEF ≤ 40%, and EMPHASIS-HF trial of eplerenone vs placebo in less symptomatic HFrEF (LVEF ≤ 35%, NYHA II) altogether suggest MRAs confer improvements in all-cause mortality, HF hospitalizations, and sudden cardiac death in patients with HFrEF. Importantly, these benefits have been demonstrated across a wide range of HFrEF severity and etiologies, including ischemic cardiomyopathy (Option D).
Therefore, in patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter to minimize risk of hyperkalemia and renal insufficiency (Class 1, LOE A). MRA therapy in this context provides high economic value.
Adverse Effects of MRAs
Both spironolactone and eplerenone are excreted by the kidney and due to their inhibition of aldosterone signaling, reduce potassium excretion in the urine. For these reasons, the initiation of MRAs is contraindicated in patients with eGFR of ≤30 mL/min/1.73m2 or serum potassium levels of ≥5.0 mEq/L. After starting or intensifying MRA therapy, serum potassium levels and renal function should be rechecked at approximately 1 week, at 4 weeks, and every 6 months thereafter, provided clinical stability. Hyperkalemia can increase the risk of ventricular arrhythmias and death. Unfortunately, this often results in de-escalation or discontinuation of RAASi and a subsequent loss of long-term cardiorenal benefits of maximally tolerated GDMT.
The utility of prescribing potassium binders (e.g., patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating continuation of Patiromer and sodium zirconium cyclosilicate remove potassium by exchanging cations leading to increased fecal excretion and thereby lowering serum potassium levels. These have been FDA approved for treatment of hyperkalemia for patients receiving RAASi.
Therefore, the use of potassium binders (patiromer, sodium zirconium cyclosilicate) to improve outcomes by facilitating the continuation of RAASi therapy in patients with HF who experience hyperkalemia (serum potassium level ≥5.5 mEq/L) received a Class 2b recommendation (LOE B-R), but overall utility remains uncertain.
In the DIAMOND trial, patients with HFrEF and hyperkalemia were randomized to patiromer vs. control. In the run-in phase, all patients were started on patiromer, and subsequently, RAASi therapy was initiated/optimized. After this, patients were randomized to continue vs stop patiromer. Hard clinical primary endpoints of time to CV death or first CV hospitalization were changed to mean change in serum potassium due to challenges with recruitment related to the COVID-19 pandemic. There was a significant reduction in the mean change of potassium (0.03 mEq/L in the patiromer group vs. 0.13 mEq/L in the control). Additionally, 85% of the patiromer arm was able to be optimized on RAASi.
Aside from hyperkalemia, troublesome side effects of MRAs include gynecomastia and vaginal bleeding. Eplerenone results in lower rates of these side effects than spironolactone given greater specificity for the aldosterone receptor (Option C).
Main Takeaway
Mineralocorticoid receptor antagonists, like spironolactone and eplerenone, reduce all-cause mortality, HF hospitalizations, and sudden cardiac death in a wide range of patients with HFrEF. Monitoring renal function and potassium levels while on MRA therapy is imperative.
Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Question #38
Mrs. M is a 65-year-old woman with non-ischemic dilated cardiomyopathy (LVEF 40%) and moderate to severe mitral regurgitation (MR) presenting for outpatient follow-up. Despite improvement overall, she continues to experience dyspnea on exertion with two flights of stairs and occasional PND. She reports adherence with her medication regimen of sacubitril-valsartan 97-103mg twice daily, metoprolol succinate 200mg daily, spironolactone 25mg daily, empagliflozin 10mg daily, and furosemide 80mg daily. A transthoracic echocardiogram today shows an LVEF of 35%, an LVESD of 60 mm, severe MR with a regurgitant fraction of 60%, and an estimated right ventricular systolic pressure of 40 mmHg. Her EKG shows normal sinus rhythm at 65 bpm and a QRS complex width of 100 ms.
What is the most appropriate recommendation for management of her heart failure?
A
Continue maximally tolerated GDMT; no other changes
B
Refer for cardiac resynchronization therapy (CRT)
C
Refer for transcatheter mitral valve intervention
Answer #38
Explanation
Choice C is correct. The 2020 ACC/AHA Guidelines for the management of patients with valvular heart disease outline specific recommendations.
In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent symptoms (NYHA class II, III, or IV) while on optimal GDMT for HF (Stage D), M-TEER is reasonable in patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mmHg (Class 2a, LOE B-R).
Conversely, mitral valve surgery may have a role in the following contexts:
Severe secondary MR when CABG is planned (Class 2a, LOE B-NR)
Chronic severe secondary MR related to atrial annular dilation with preserved LV systolic function (LVEF ≥50%) who have severe persistent symptoms (NYHA class III or IV) despite therapy for HF and therapy for associated AF or other comorbidities (Stage D) (Class 2b, LOE B-NR)
Chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent severe symptoms (NYHA class III or IV) while on optimal GDMT for HF (Stage D) (Class 2b, LOE B-NR).
Choice A is incorrect. GDMT has been shown to improve MR and LV dimensions in patients with HFrEF and secondary MR, and it is a Class 1 recommendation (LOE B-R) to optimize GDMT before any intervention for secondary MR related to LV dysfunction. This includes both medical GDMT and cardiac resynchronization therapy (CRT) where appropriate. Our patient is still having symptoms despite being on the maximally tolerated doses of medical GDMT. This highlights the importance of a multidisciplinary approach to the management of valvular heart disease in patients with HF in accordance with clinical practice guidelines to prevent worsening of HF and adverse clinical outcomes (Class 1, LOE B-R). A cardiologist with expertise in the management of HF is integral in the shared decision-making for valve intervention and should guide optimization of GDMT to ensure that medical options for HF and secondary MR have been effectively applied for an appropriate time-period and exhausted before considering intervention.
Choice B is incorrect. While CRT has been shown to improve MR, LV dimensions, and outcomes in patients with HFrEF and secondary MR in appropriately selected patients, our patient would not be a candidate given that her QRS duration was < 120ms (Class 3: no benefit, LOE B-R).
Main Takeaway
In patients with severe secondary MR and reduced ejection fraction with persistent symptoms despite GDMT, M-TEER is reasonable in patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mmHg. Conversely, surgery may be appropriate for some patients. HF ad VHD should be managed in a multidisciplinary fashion.
Guideline Loc.
Sections 7.4-7.5
Figure 10
Also: Section 7.3 from “Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., rwin, J. P., Gentile, F., Jneid, H., Krieger, ric v., Mack, M., McLeod, C., O’Gara, P. T., Rigolin, V. H., Sundt, T. M., Thompson, A., & Toly, C. (2021). 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. In Circulation (Vol. 143, Issue 5, pp. E72–E227). Lippincott Williams and Wilkins. https://doi.org/10.1161/CIR.0000000000000923”
400. Cardio-Rheumatology: Targeting Inflammation for Cardiovascular Risk Reduction with Dr. Paul Ridker
Nov 06, 2024
In this episode, Dr. Paul Ridker, a pioneer in the field of cardiovascular inflammation, joins the CardioNerds (Dr. Gurleen Kaur, Dr. Richard Ferraro, and Dr. Nidhi Patel) to discuss the evolving landscape of inflammation as a key factor in cardiovascular risk reduction. The discussion dives into the importance of biomarkers like high-sensitivity C-reactive protein (hs-CRP) in guiding treatment strategies, the insights gleaned from landmark trials like the JUPITER and CANTOS studies, and the future of targeted anti-inflammatory therapies in cardiology.
Show notes were drafted by Dr. Nidhi Patel. Audio editing by CardioNerds academy intern, Grace Qiu.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday.Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Pearls – Targeting Inflammation for Cardiovascular Risk
“If you don’t measure it, you can’t treat it”: Incorporate hs-CRP into routine practice for patients at risk of cardiovascular events, as it provides crucial information for risk stratification and management.
Recognize the dual benefits of statins in lowering both LDL and inflammation, particularly in patients with elevated hs-CRP.
Encourage patients to adopt heart-healthy habits, as lifestyle changes remain foundational in reducing both cholesterol and inflammatory risk.
Reminder that most autoimmune or inflammatory diseases, from psoriasis to Addison’s disease to lupus to scleroderma to inflammatory bowel disease, have been shown to have elevated cardiovascular risk
Ongoing randomized trials including ZEUS, HERMES, and ARTEMIS will inform whether novel targeting of IL-6 can safely lower cardiovascular event rates or slow renal progression
Show notes – Targeting Inflammation for Cardiovascular Risk
Why is it important to measure both LDL and hs-CRP, and what factors increase hs-CRP?
Inflammation and hyperlipidemia are synergistic in promoting atherosclerosis. They interact to exacerbate plaque formation and instability, increasing the risk of cardiovascular events.
Just like we measure blood pressure and LDL to know what to treat, we should measure hs-CRP to guide targeted therapy.
Clinical Example: in Ms. Flame’s case, despite achieving target LDL levels with statins, her elevated hs-CRP indicates ongoing inflammation and residual cardiovascular risk that should be assessed.
Residual inflammatory risk should be assessed in both primary and secondary prevention.
Increased BMI1, smoking2, a sedentary lifestyle3, and genetics4 (such as a higher risk of metabolic disease in South Asians) all raise hs-CRP levels.
SGLTi5 and GLP-1 agonists6 have also been shown to decrease hs-CRP levels.
What data do we have to support measuring hs-CRP?
Women’s Health Study7: an early study showing that hs-CRP predicted risk at least as well as LDL cholesterol and that models incorporating hs-CRP in addition to lipids were significantly better at predicting risk than models based on lipids alone.
JUPITER Trial8 (Primary Prevention): Among patients with normal LDL but elevated hs-CRP there was a 44% reduction in major cardiovascular events (>50% in MI and stroke) and a 20% reduction in all-cause mortality in patients treated with statins. These results led to changes in guidelines in recognizing the need to measure and treat inflammation.
CANTOS Trial9 (Secondary Prevention): Randomized >10K patients with previous MI and hs-CRP ≥ 2mg/L and found that canakinumab reduced hs-CRP level from baseline in a dose-dependent manner, without reduction in the LDL, ApoB, TG, or blood pressure.
What are the guidelines and supportive data on using Colchicine?
Colchicine 0.5 mg is the first FDA-approved anti-inflammatory therapy indicated for reducing cardiovascular events among adults who have established ASCVD or are at risk of developing it.
The use of Colchicine is supported by the LoDoCo, LoDoCo-2, and COLCOT trials, which showed a ~25-30% risk reduction in cardiovascular risk. In comparison, studies using ezetimibe10 have shown a 6-7% relative risk reduction and PCSK9 inhibitors11 ~15% risk reduction for LDL reduction.
LoDoCo12– in those with stable CAD, patients who received colchicine in addition to standard of care had a significantly lower composite rate of ACS compared to those who only received standard of care at a median follow-up of 3 years.
LoDoCo-213– randomized control, multicentric trial in patients with stable CAD showing group randomized to colchicine + standard of compare had reduced MACE compared to those with placebo + standard of care at a median follow-up of 2.8 years.
COLCOT14– Addition of colchicine within 30 days of ACS resulted in a reduction of the primary composite outcome of cardiovascular death, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization for angina
What are examples of ongoing trials that will shape the future of our anti-inflammatory toolbox?
ZEUS Trial15– ongoing trial that randomizes patients with ASCVD, hs-CRP ≥ 2 and CKD (eGFR between 15-60 OR EGFR ≥ 60 and urinary albumin-to-creatinine ratio ≥200) to Ziltivekimab or placebo, and assesses time to first occurrence of MACE.
Hermes HFpEF16– ongoing trial that randomizes patients with HFpEF and HFmrEF to Ziltivekimab or placebo, and assesses time to first occurrence of cardiovascular death, heart failure hospitalization, or urgent heart failure visit
Artemis Acute Ischemia17– ongoing trial that randomizes patients hospitalized with MI to Ziltivekimab or placebo, and assess time to MACE.
Clazakizumab in patients receiving maintenance dialysis18– this study randomized adults with known cardiovascular disease and/or DM2 receiving dialysis with hs-CRP ≥ 2 to receive Clazakizumab or placebo. The primary endpoint is a reduction in hs-CRP over 12 weeks.
References – Targeting Inflammation for Cardiovascular Risk
Visser M, Bouter LM, McQuillan GM, Wener MH, Harris TB. Elevated C-Reactive Protein Levels in Overweight and Obese Adults. JAMA. 1999;282:2131-2135. doi: 10.1001/jama.282.22.2131
Tonstad S, Cowan JL. C-reactive protein as a predictor of disease in smokers and former smokers: a review. Int J Clin Pract. 2009;63:1634-1641. doi: 10.1111/j.1742-1241.2009.02179.x
Esteghamati A, Morteza A, Khalilzadeh O, Anvari M, Noshad S, Zandieh A, Nakhjavani M. Physical inactivity is correlated with levels of quantitative C-reactive protein in serum, independent of obesity: results of the national surveillance of risk factors of non-communicable diseases in Iran. J Health Popul Nutr. 2012;30:66-72. doi: 10.3329/jhpn.v30i1.11278
Anand SS, Razak F, Yi Q, Davis B, Jacobs R, Vuksan V, Lonn E, Teo K, McQueen M, Yusuf S. C-reactive protein as a screening test for cardiovascular risk in a multiethnic population. Arterioscler Thromb Vasc Biol. 2004;24:1509-1515. doi: 10.1161/01.ATV.0000135845.95890.4e
La Grotta R, de Candia P, Olivieri F, Matacchione G, Giuliani A, Rippo MR, Tagliabue E, Mancino M, Rispoli F, Ferroni S, et al. Anti-inflammatory effect of SGLT-2 inhibitors via uric acid and insulin. Cell Mol Life Sci. 2022;79:273. doi: 10.1007/s00018-022-04289-z
Mazidi M, Karimi E, Rezaie P, Ferns GA. Treatment with GLP1 receptor agonists reduce serum CRP concentrations in patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials. J Diabetes Complications. 2017;31:1237-1242. doi: 10.1016/j.jdiacomp.2016.05.022
Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342:836-843. doi: 10.1056/nejm200003233421202
Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM, Jr., Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008;359:2195-2207. doi: 10.1056/NEJMoa0807646
Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, Fonseca F, Nicolau J, Koenig W, Anker SD, et al. Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease. New England Journal of Medicine. 2017;377:1119-1131. doi: 10.1056/NEJMoa1707914
Cannon CP, Blazing MA, Giugliano RP, McCagg A, White JA, Theroux P, Darius H, Lewis BS, Ophuis TO, Jukema JW, et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. New England Journal of Medicine. 2015;372:2387-2397. doi: 10.1056/NEJMoa1410489
Sabatine MS, Giugliano RP, Keech AC, Honarpour N, Wiviott SD, Murphy SA, Kuder JF, Wang H, Liu T, Wasserman SM, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. New England Journal of Medicine. 2017;376:1713-1722. doi: 10.1056/NEJMoa1615664
Nidorf SM, Eikelboom JW, Budgeon CA, Thompson PL. Low-dose colchicine for secondary prevention of cardiovascular disease. J Am Coll Cardiol. 2013;61:404-410. doi: 10.1016/j.jacc.2012.10.027
Nidorf SM, Fiolet ATL, Mosterd A, Eikelboom JW, Schut A, Opstal TSJ, The SHK, Xu XF, Ireland MA, Lenderink T, et al. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med. 2020;383:1838-1847. doi: 10.1056/NEJMoa2021372
Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, Pinto FJ, Ibrahim R, Gamra H, Kiwan GS, et al. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. N Engl J Med. 2019;381:2497-2505. doi: 10.1056/NEJMoa1912388
ZEUS – Effects of Ziltivekimab Versus Placebo on Cardiovascular Outcomes in Participants With Established Atherosclerotic Cardiovascular Disease, Chronic Kidney Disease and Systemic Inflammation. In; 2021.
Effects of Ziltivekimab Versus Placebo on Morbidity and Mortality in Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction and Systemic Inflammation. In; 2022.
ARTEMIS – Effects of Ziltivekimab Versus Placebo on Cardiovascular Outcomes in Patients With Acute Myocardial Infarction. In: Duke Clinical Research I, ed.; 2023.
Chertow GM, Chang AM, Felker GM, Heise M, Velkoska E, Fellström B, Charytan DM, Clementi R, Gibson CM, Goodman SG, et al. IL-6 inhibition with clazakizumab in patients receiving maintenance dialysis: a randomized phase 2b trial. Nature Medicine. 2024. doi: 10.1038/s41591-024-03043-1
399. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #37 with Dr. Clyde Yancy
Nov 05, 2024
The following question refers to Section 7.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the ACC/AHA Joint Committee on Clinical Practice Guidelines.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Question #37
Mr. S is an 80-year-old man with a history of hypertension, type II diabetes mellitus, and hypothyroidism who had an anterior myocardial infarction (MI) treated with a drug-eluting stent to the left anterior descending artery (LAD) 45 days ago. His course was complicated by a new LVEF reduction to 30%, and left bundle branch block (LBBB) with QRS duration of 152 ms in normal sinus rhythm. He reports he is feeling well and is able to enjoy gardening without symptoms, though he experiences dyspnea while walking to his bedroom on the second floor of his house. Repeat TTE shows persistent LVEF of 30% despite initiation of goal-directed medical therapy (GDMT). What is the best next step in his management?
A
Monitor for LVEF improvement for a total of 60 days prior to further intervention
B
Implantation of a dual-chamber ICD
C
Implantation of a CRT-D
D
Continue current management as device implantation is contraindicated given his advanced age
Answer #37
Explanation
Choice C is correct. Implantation of a CRT-D is the best next step.
In patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for >1 year,
ICD therapy is recommended for primary prevention of SCD to reduce total mortality (Class 1, LOE A). A transvenous ICD provides high economic value in this setting, particularly when a patient’s risk of death from ventricular arrhythmia is deemed high and the risk of nonarrhythmic death is deemed low.
In addition, for patients who have LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II, III, or
ambulatory IV symptoms on GDMT, cardiac resynchronization therapy (CRT) is indicated to reduce total mortality, reduce hospitalizations, and improve symptoms and QOL. Cardiac resynchronization provides high economic value in this setting.
Mr. S therefore meets criteria for both ICD and CRT.
Choice A is incorrect. All patients should be on maximally tolerated doses of GDMT prior to consideration of device implantation to allow for assessment of LVEF recovery. Patients who have experienced myocardial infarction should be reassessed 40 days after the event and after achieving maximally tolerated doses of GDMT.
Choice B in incorrect. For patients in sinus rhythm with a LBBB morphology and QRS duration >150 ms with an LVEF ≤35%, there were significant improvements in 6-minute walk test performance, quality of life, NYHA classification, and LVEF after implantation of CRT. Mortality and hospitalizations were also found to be decreased in patients with CRT-P & CRT-D. Overall, CRT has been shown to have high economic value in these patients.
It should be noted that CRT has the most benefit in patients with a wide QRS (>150 ms), LBBB morphology, and LVEF ≤35%, though trials have shown a modest benefit in special populations. CRT has a Class 2a recommendation (LOE B-NR) in patients with LVEF ≤35%, sinus rhythm, and NYHA Class II, III, or ambulatory IV symptoms on GDMT, with either:
a) Non-LBBB pattern with a QRS duration ≥150 ms
b) LBBB with a QRS duration of 120 to 149 ms
Choice D is incorrect. If LVEF remains ≤35% in a patient with a life expectancy >1 year, trials have shown that ICD placement for primary prevention reduces sudden cardiac death and also has a high economic value. There is no indication that this patient has a life expectancy < 1 year.
Main Takeaway
In patients 40 days post-MI on GDMT with an LVEF that remains ≤35%, ICD therapy for primary prevention is appropriate and cost effective. For those additional with a LBBB and QRS >150 ms, CRT-D is also appropriate and cost effective.
398. Narratives in Cardiology: Career Flexibility in Cardiology with Dr. Minnow Walsh
Oct 31, 2024
In this episode, Dr. Gurleen Kaur (Cardiology FIT at Brigham and Women’s Hospital and APD of the CardioNerds Academy) and Dr. Diane Masket (Medicine Resident at the University of Chicago Northshore and CardioNerds Academy Intern) discuss with Dr. Minnow Walsh (Medical Director of the Heart Failure and Cardiovascular programs at Ascension St. Vincent Heart Center in Indianapolis) about her personal and professional journey in Cardiology. They discuss Dr. Walsh’s authorship of the recent ACC statement on career flexibility in Cardiology, her involvement with the ACC at both the local and national levels, and her passion for making cardiology a more inclusive and welcoming field for all.
Notes were drafted by Dr. Diane Masket and episode audio was engineered by student Dr. Grace Qiu.
This episode is supported by the5th Annual Going Back to the Heart of Cardiology (A MedscapeLIVE Conference). Join co-chairs Dr. Robert Harrington and Dr. Fatima Rodriguez January 24-26, 2025 at the Fontainebleau Hotel in Miami Beach, Florida.
The agenda will explore the latest advancements in cardiology including cardiovascular prevention, atherosclerosis and thrombosis, cardiovascular dysfunction, arrhythmias, and valvular heart disease. Network, attend engaging presentations by renowned cardiologists, visit the exhibit and poster hall, participate in an exclusive immersive experience, and earn up to 13 CME/CE credits.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
“You have to learn to live with ambivalence. You can’t do everything. You can’t do everything all at one time”
“One of the most important things the College is behind and pushing, is that competency-based evaluation is what should be used in fellowship rather than this sort of cookie cutter approach where you have to do these many months of echo and this much of cath lab. So, I think flexibility moving from volume to competency is one push.”
“Fellowship is daunting, and internal medicine residency is too, but I think culture is how we feel every day. And I think the more we increase flexibility the more that culture is going to shift.
Notes – Career Flexibility in Cardiology
Process of developing ACC Health Policy Statements
These documents address issues that require ACC influence and usually involve a variety of institutions, governing bodies, and other stakeholders. ACC comes to an agreement on how they will approach this topic and shares it broadly.
Most of the existing ACC health policy statements are disease-based instead of profession-based. The ACC Career Flexibility statement grew out of the diversity, equity, and inclusion task force, which is a standing committee.
A variety of authors are included in health policy statements to reflect the perspectives of many different interest groups.
All policy statements, including the one about career flexibility, are available online on JACC.org 1
Major Components of the ACC Career Flexibility Health Policy Statement
There are 18 principles that highlight the most important aspects regarding career flexibility in cardiology.2
Flexibility allows for deceleration (decrease in work hours, responsibilities, etc.) and acceleration based on the needs of the physician. For example, during childbearing and rearing time periods, there could be a deceleration, which could accelerate when parenthood responsibilities have decreased.
It does not only need to be based around parenting; physicians who are not parents also desire flexibility and enjoy spending time on activities other than their careers. These needs will be unique for each person.
Individuals seeking flexibility also must understand that there will be an adjustment in their compensation as they are no longer working full-time.
Career flexibility is beneficial at all stages with a desire for a safe training environment early, ability to decelerate mid-career to focus on other priorities and late career to possibly accelerate and works towards a tenure.
Allowing flexibility in cardiology is a major pathway to increasing diversity in the workforce which ultimately creates a more inclusive and welcoming environment.
Both men and women in cardiology are interested in flexibility. For many years there was a belief that only women wanted this flexibility; however, in recent years it has become apparent that all cardiologists seek the opportunity for a better work-life balance.
Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She has been a PI Mentor for the CardioNerds Clinical Trials Program.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
Question #36
A 50-year-old woman presents to establish care. Her medical history includes COPD, prediabetes, and hypertension. She is being treated with chlorthalidone, amlodipine, lisinopril, and a tiotropium inhaler. She denies chest pain, dyspnea on exertion, or lower extremity edema.
On physical exam, blood pressure is 154/88 mmHg, heart rate is 90 beats/min, and respiration rate is 22 breaths/min with an oxygen saturation of 94% breathing ambient room air. BMI is 36 kg/m2. Jugular venous pulsations are difficult to assess due to her body habitus. Breath sounds are distant, with occasional end-expiratory wheezing. Heart sounds are distant, and extra sounds or murmurs are not detected. Extremities are warm and without peripheral edema. B-type natriuretic peptide level is 28 pg/mL (28 ng/L).
A chest radiograph shows increased radiolucency of the lungs, flattened diaphragms, and a narrow heart shadow consistent with COPD. An electrocardiogram shows evidence of left ventricular hypertrophy. The echocardiogram showed normal LV and RV function with no significant valvular abnormalities.
In which stage of HF would this patient be classified?
A
Stage A: At Risk for HF
B
Stage B: Pre-HF
C
Stage C: Symptomatic HF
D
Stage D: Advanced HF
Answer #36
Explanation
The correct answer is A – Stage A or at risk for HF.
This asymptomatic patient with no evidence of structural heart disease or positive cardiac biomarkers for stretch or injury would be classified as Stage A or “at risk” for HF.
The ACC/AHA stages of HF emphasize the development and progression of disease with specific therapeutic interventions at each stage. Advanced stages and disease progression are associated with reduced survival. The stages were revised in this edition of guidelines to emphasize new terminologies of “at risk” for Stage A and “pre-HF” for Stage B.
At Stage A, emphasis is placed on the prevention of structural heart disease by aggressive risk factor modification. Healthy lifestyle habits, including regular physical activity, maintaining a normal weight, healthy dietary habits, and avoiding smoking, help reduce the future risk of HF.
For patients with established hypertension, coronary disease, or diabetes, optimal control of risk factors is crucial.
For hypertension, the SPRINT trial and subsequent meta-analysis of 35 BP-lowering trials have demonstrated a substantial reduction in incident HF and mortality with aggressive BP control.
For diabetes, SGLT2 inhibitors have demonstrated reductions in HF hospitalizations regardless of baseline HF status.
Screening patients “at risk” for HF for disease progression may be beneficial. The STOP-HF study randomized patients with risk factors but without established LV systolic dysfunction or symptomatic HF to screening with BNP testing or usual care. Screening with BNP followed by an echocardiogram and referral to a cardiovascular specialist for those with levels ≥50 pg/mL led to a reduction in the composite endpoint of incident asymptomatic LV dysfunction with or without newly diagnosed HF. Accordingly, BNP or NT–proBNP–based screening followed by team-based care, including a cardiovascular specialist, has a Class 2a (LOE B-R) recommendation in patients at risk of developing HF to prevent the development of LV dysfunction or new-onset HF.
Our patients should be counseled on healthy lifestyles, smoking cessation, and weight loss. Her anti-hypertensive regimen should be intensified for blood pressure optimization. Her ASCVD risk should be calculated, and counseling regarding statin use should be provided accordingly. If she develops overt diabetes, she should be started on an SGLT-2 inhibitor. Given her BNP level, she does not currently warrant further evaluation with an echocardiogram or referral to a specialist.
Main Takeaway
Patients with Stage A HF are those who are at risk for HF but are without symptoms, structural heart disease, or cardiac biomarkers of stretch or injury. At this stage, the emphasis should be on identifying and modifying risk factors.
The case discussed involves a 76-year-old woman with a history of monoclonal gammopathy of undetermined significance, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and squamous cell carcinoma was admitted to the hospital for worsening shortness of breath, swelling in lower extremities, hyponatremia, and urinary tract infection. CT chest to evaluate for pulmonary embolism showed incidental pericardial calcifications; the heart failure team was consulted for the management of her decompensated heart failure. Echo images were nondiagnostic. Subsequent invasive hemodynamic monitoring showed elevated right and left-sided filling pressures, diastolic equalization of LV and RV pressures, and positive RV square root sign with ventricular interdependence. Cardiac MRI showed septal flattening on deep inspiration and septal bounce, suggestive of interventricular dependence. After a heart team discussion and with shared-decision making the patient opted for medical management owing to her comorbidities and frailty.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday.Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Echo: Left Ventricular ejection fraction = 55-60%. Unclear septal motion in the setting of atrial fibrillation
MRI: Diastolic septal flattening with deep inspiration as well as a septal bounce suggestive of interventricular dependence and constrictive physiology
395. Beyond the Boards: Channelopathies with Dr. Michael Ackerman
Oct 10, 2024
Dr. Amit Goyal, along with episode chair Dr. Dinu Balanescu (Mayo Clinic, Rochester), and FIT leads Dr. Sonu Abraham (University of Kentucky) and Dr. Natasha Vedage (MGH), dive into the fascinating topic of channelopathies with Dr. Michael Ackerman, a genetic cardiologist and professor of medicine, pediatrics, and pharmacology at Mayo Clinic, Rochester, Minnesota. Using a case-based approach, they review the nuances of diagnosis and treatment of channelopathies, including Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), and long QT syndrome. Dr. Sonu Abraham drafted show notes. Audio engineering for this episode was expertly handled by CardioNerds intern, Christiana Dangas.
American Heart Association’s Scientific Sessions 2024
As heard in this episode, the American Heart Association’s Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It’s a special year you won’t want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday.Registration is now open, secure your spot here!
When registering, use code NERDS and if you’re among the first 20 to sign up, you’ll receive a free 1-year AHA Professional Membership!
One cannot equate the presence of type 1 Brugada ECG pattern to the diagnosis of Brugada syndrome. Clinical history, family history, and/or genetic testing results are required to make a definitive diagnosis.
The loss-of-function variants in the SCN5A gene, which encodes for the α-subunit of the NaV1.5 sodium channel, is the only Brugada susceptibility gene with sufficient evidence supporting pathogenicity.
Exertional syncope is an “alarm” symptom that demands a comprehensive evaluation with 4 diagnostic tests: ECG, echocardiography, exercise treadmill test, and Holter monitor. Think of catecholaminergic polymorphic ventricular tachycardia (CPVT) in a patient with exertional syncope and normal EKG!
ICD therapy is never prescribed as monotherapy in patients with CPVT. Medical therapy with a combination of nadolol plus flecainide is the current standard of care.
Long QT syndrome is one of the few clinical scenarios where genetic testing clearly guides management, particularly with respect to variability in beta-blocker responsiveness.
Notes – Channelopathies
1. What are the diagnostic criteria for Brugada syndrome (BrS)?
Three repolarization patterns are associated with Brugada syndrome in the right precordial leads (V1-V2):
Type 1: Prominent coved ST-segment elevation displaying J-point amplitude or ST-segment elevation ≥2 mm, followed by a negative T wave.
Type 2/3: Saddleback ST-segment configuration with variable levels of ST-segment elevation.
It is important to note that only a type 1 pattern is diagnostic for Brugada syndrome, whereas patients with type 2/3 patterns may benefit from further testing.
The Shanghai score acknowledges that relying solely on induced type 1 ECG changes has limitations. Therefore, one cannot equate the presence of a type 1 Brugada ECG pattern alone to the diagnosis of Brugada syndrome. The score suggests incorporating additional information—such as clinical history, family history, and/or genetic testing results—to achieve a definitive diagnosis.
2. What is the significance of genetic testing in Brugada syndrome?
There are 23 alleged Brugada syndrome susceptibility genes published with varying levels of evidence. However, only one gene mutation, the loss-of-function variants in the SCN5A gene encoding for the α-subunit of the NaV1.5 sodium channel, is considered to have sufficient evidence.
The overall yield of BrS genetic testing is 20%. The presence of PR prolongation (>200 ms) along with type I EKG pattern increases the yield to 40%. On the contrary, in the presence of a normal PR interval, the likelihood of SCN5A positivity drops to <10%.
3. How would you risk-stratify a patient with Brugada syndrome?
Serious arrhythmic events (SAE), including resuscitated cardiac arrest and sudden cardiac death, rarely represent the initial symptoms of Brugada syndrome. Thus, risk stratification is important.
Factors that increase risk include:
Resuscitated cardiac arrest or history of cardiogenic syncope and the presence of a spontaneous type 1 ECG.
Positive genetic test – certain SCN5A variants were independent predictors for SAE.
Inducibility during programmed ventricular stimulation (EP study) using a double stimulation protocol (annualized risk is 1.5% per year for a positive study and 0.5% per year for a negative study).
4. What are the treatment options for Brugada syndrome?
The only drug with therapeutic potential in BrS is quinidine. The antiarrhythmic effect is achieved by prolonging the effective refractory period via inhibition of Ito potassium channel.
BrS plus a history of cardiac arrest, sustained VT, or syncope judged to be caused by ventricular arrhythmia would warrant an ICD.
In those refractory to first-line therapies, RVOT epicardial ablation is now an additional therapeutic option.
5. What are the four diagnostic tests to be done in a patient who presents with an episode of exertional syncope?
Exertional syncope is a high-risk presentation that demands a comprehensive evaluation! This includes:
EKG
Echocardiogram
Exercise treadmill test
Holter monitor
Do not stop at an EKG and echo alone!
Think of catecholaminergic polymorphic ventricular tachycardia (CPVT) in a patient with exertional syncope and a normal EKG!
6. What are the features on the exercise treadmill test that increase the suspicion for CPVT?
Bidirectional VT is considered a hallmark of CPVT, with digoxin toxicity being the only real imitator. This finding is specific in the absence of digoxin but not sensitive.
During exercise testing in CPVT, as the patient’s heart rate rises with increasing workload, PVCs begin to appear, progressing to bigeminy, couplets, and, in some instances, bidirectional couplets. The ectopy typically vanishes within 30 seconds of the recovery phase. This pattern increases suspicion of CPVT and warrants a detailed family history and genetic testing.
7. What are the genetic underpinnings of CPVT?
Mutations in the ryanodine receptor (RyR2 gene) render calcium release channels leaky, leading to diastolic calcium overload. This ultimately triggers arrhythmias in CPVT.
8. What are therapeutic interventions for a patient with CPVT?
Medical therapy is the mainstay of treatment in CPVT. Drugs include non-selective beta-blockers like nadolol or propranolol. Standard of care currently includes a combination of nadolol plus flecainide. An ICD is indicated only in the case of an aborted cardiac arrest. ICD therapy is never prescribed as monotherapy in these patients.
9. How do we correctly measure the QTc?
The QT interval is measured from the beginning of the QRS complex to the end of the T wave. The end of the T wave is determined using the maximum slope intercept method, in which a tangent line is drawn through the maximum down slope of the T wave. The point at which this tangent line crosses the isoelectric line is the end of the T wave. The U wave is excluded.
Best measured in leads II or V5.
Quick eyeball test: if the QT interval is more than ½ the RR interval, the QTc will be >460 ms.
10. What are the three primary mutations implicated in Long QT syndrome?
LQT1 (30-40% of cases)
Mutation: loss of function in potassium channel gene KCNQ1
ECG: broad-based T wave
Trigger: activity, adrenaline, exercise
BB responsiveness: +++ (nadolol or propranolol)
LQT2 (second most common)
Mutation: loss of function in potassium channel gene KCNH2
ECG: notched T wave
Trigger: auditory (alarm clock), post-partum
BB responsiveness: ++
LQT3
Mutation: gain of function or leakiness of sodium channel SCN5A (note: BrS is due to loss of function in the same gene)
ECG: normal T wave after prolonged isoelectric ST segment
Trigger: none, but typically happens during rest
BB responsiveness: + (propranolol); may consider combination therapy with mexiletine or mexiletine monotherapy.
394. 3rd Annual Sanjay V. Desai Lecture: Artificial Intelligence in Medical Education with Dr. Kathryn Berlacher, Dr. Melissa McNeil, and Dr. Alfred Shoukry
Oct 02, 2024
The CardioNerds Academy is excited to present the 3rd Annual Sanjay V. Desai Lecture in Medical Education, featuring a deep dive into the evolving role of Artificial Intelligence in Medical Education. Join us as Dr. Kathryn Berlacher, Dr. Melissa McNeil, and Dr. Alfred Shoukry explore the transformative potential of AI in training future healthcare professionals and enhancing educational methodologies. Their insightful discussion sheds light on the integration of cutting-edge technologies to improve medical learning and patient care. The conversation is faciliated by Dr. Tommy Das, Program Director of the CardioNerds Academy, and CardioNerds Academy Chiefs: Dr. Callie Clark, Dr. Rachel Goodman, Dr. Ronaldo Correa Fabiano, and Dr. Claire Cambron, who bring their expertise and enthusiasm to this engaging discussion on the future of medical education. Special thanks to Pace Wetstein, CardioNerds academy intern, for his exceptional audio editing in this episode.
Dr. Kathryn Berlacher is a graduate of The Ohio State University College of Medicine and completed her internal medicine residency, chief residency, and cardiology fellowship at UPMC, where she has been on faculty since 2012. She earned a master's degree in medical education from the University of Pittsburgh and has served as the Program Director of the Cardiovascular Fellowship Program since 2015. In 2021, she was appointed Associate Chief of Education for the UPMC Heart and Vascular Institute. Additionally, Dr. Berlacher is the director of the McGee Women's Heart Program and chief of medicine at McGee Women's Hospital. Nationally, she serves as the chair for the American College of Cardiology’s Annual Scientific Sessions for 2025 and 2026, regularly speaking on women's cardiology, medical education, diversity, inclusion, and health equity.Dr. Alfred Shoukry graduated from Northwestern University with dual degrees in Neurobiology and Biomedical Engineering. He completed medical school and internal medicine residency at UPMC, where he also earned a certificate in medical education. Dr. Shoukry serves as core faculty at the University of Pittsburgh School of Medicine and cares for patients at the VA in Pittsburgh. As the course director for Population Health, he teaches on topics such as patient safety, quality improvement, and bioinformatics. He is an expert on the impact of large language models in medical education, presenting locally and nationally on the subject.Dr. Melissa McNeil received her undergraduate degree from Princeton University, her MD from the University of Pittsburgh, and a Master of Public Health from the same institution. She is a professor emeritus of medicine at the University of Pittsburgh and recently joined the faculty at Brown University as a professor of medicine. Dr. McNeil serves as an academic hospitalist and senior consultant to the Women's Health Division at Brown. Her expertise lies in developing training programs to foster leaders in women's health education and research. She has been recognized nationally for her contributions, including being named the Society of General Internal Medicine Distinguished Professor of Women's Health in 2014 and receiving their Career Achievement in Medical Education award in 2016.
Dr. Sanjay V Desai serves as the Chief Academic Officer, The American Medical Association and is the former Program Director of the Osler Medical Residency at The Johns Hopkins Hospital.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
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393. SGLT Inhibitors: Clinical Implementation of SGLT Inhibitors with Dr. Alison Bailey
Oct 01, 2024
CardioNerds Drs. Jason Feinman, Gurleen Kaur, and Rick Ferraro discuss the implementation of SGLT inhibitors in clinical practice with Dr. Alison Bailey. Notes were drafted by Dr. Jason Feinman.
In this episode, we discuss the implementation of SGLTi in clinical practice scenarios, including for individuals with heart failure regardless of ejection fraction, those with chronic kidney disease, and those with diabetes mellitus. The group also discusses important side effects to monitor for, as well as how to counsel patients when prescribing these medications.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals.
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Pearls - Clinical Implementation of SGLT Inhibitors
For patients with heart failure with reduced ejection fraction, SGLT inhibitors reduce the composite outcome of cardiovascular death or heart failure hospitalization by 25%.
SGLT inhibitors can be safely started in patients with an eGFR as low as 20. There are ongoing trials investigating the safety of these medications in individuals with eGFR lower than 20 or those who are receiving dialysis.
An eGFR decrease of 3-5 ml/min on average is expected after starting an SGLTi, but this will stabilize over time and provides protective effects of renal dysfunction in the long run.
Early data that suggested an association between SGLTi and bacterial UTI development hasn’t panned out in the long run, but there is an association between SGLTi and the development of either genital mycotic infections or yeast infections. Perineal hygiene is important to prevent the development of either.
A patient-centered, shared decision-making approach should guide the choice of agents for individuals with type 2 diabetes mellitus. In certain patients, it may be reasonable to choose an SGLTi as the first-line agent.
Show notes - Clinical Implementation of SGLT Inhibitors
What is the data supporting the use of SGLTi in HFpEF?
The EMPEROR-Preserved and DELIVER trials investigated the impact of empagliflozin and dapagliflozin, respectively, on cardiovascular outcomes in patients with mildly reduced or preserved ejection fraction.
The SOLOIST-WHF trial investigated a combined SGLT1/2 inhibitor, sotagliflozin, in patients with recently worsening heart failure, irrespective of ejection.SGLTi have been demonstrated to reduce the risk of cardiovascular death or worsening heart failure, including heart failure hospitalization, in these individuals.
A meta-analysis of the EMPEROR-Preserved and DELIVER trials demonstrated a hazard ratio of 0.80 for cardiovascular death or first hospitalization for heart failure for empagliflozin or dapagliflozin over placebo in the setting of HFpEF.
What is the data supporting the use of SGLTi in HFrEF?
In addition to the SOLOIST-WHF trial that was previously discussed, the EMPEROR-HF and DAPA-HF investigated the impact of SGLTi medications in patients with HFrEF.
In patients with HFrEF, SGLTi medications have been demonstrated to reduce the risk of either cardiovascular death or heart failure hospitalization.
Dapagliflozin and empagliflozin had a pooled risk reduction of all-cause death of 13%, a pooled risk reduction of cardiovascular death of 14%, and a 26% reduction in the combination of CV death or first hospitalization for heart failure.
What is the expected impact of SGLTi on renal function?
Dapagliflozin, empagliflozin, sotagliflozin, ertugliflozin, and canagliflozin have all been studied for their impact on renal dysfunction in individuals both with and without diabetes.
In the CANVAS trial,
392. Case Report: Heart Failure Out of the Blue, A Case of Cobalt Cardiomyopathy – Georgetown University
Sep 23, 2024
CardioNerds (Amit Goyal) join Dr. Merna Hussien, Dr. Akhil Kallur, Dr. Abhinav Saxena, and Dr. Brody Deb from the MedStar Georgetown - Washington Hospital Center in DC for a stroll around Rock Creek Park as they discuss an unusual case of cobalt cardiomyopathy. Expert commentary is provided by Dr. Nana Afari Armah. Episode audio was edited by CardioNerds Intern Christiana Dangas.
The case is of a middle-aged woman with a past medical history of hypertension, hyperlipidemia, and bilateral hip replacements, who presented with subacute progressive exertional dyspnea, orthopnea, and constitutional symptoms and was found to have SCAI Stage C cardiogenic shock. Transthoracic echocardiogram showed severely reduced left ventricular ejection fraction (LVEF, 20-25%) and a moderate pericardial effusion. Cardiac catheterization revealed biventricular failure with elevated filling pressures. A cardiac MRI showed diffuse late gadolinium enhancement (LGE) in the left ventricle. Endomyocardial biopsy showed nonspecific chronic inflammation. However, the evidence of mitochondrial heavy metal toxicity and elevated cobalt levels made the diagnosis of cobalt cardiomyopathy. The patient underwent revision of hip joint implants to ceramic implants and started chelation therapy. However, due to persistent stage D heart failure despite normalization of cobalt levels, she underwent orthotropic heart transplantation.
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Case MEdia - Cobalt Cardiomyopathy
Pearls - Cobalt Cardiomyopathy
A good history goes a long way in diagnosing non-ischemic cardiomyopathy (NICM).
Common problems can have uncommon presentations requiring a high degree of suspicion for diagnosis.
Imaging features can overlap between causes of NICM. History helps in targeting further histological workup and uncovering the root cause.
Multidisciplinary effort is essential in making a rare diagnosis.
Taken from1 - Singh M, Krishnan M, Ghazzal A, Halushka M, Tozzi JE, Bunning RD, Rodrigo ME, Najjar SS, Molina EJ, Sheikh FH. From Hip to Heart: A Comprehensive Evaluation of an Infiltrative Cardiomyopathy. CJC Open. 2021 Nov 1;3(11):1392–5.
Notes - Cobalt Cardiomyopathy
How common is cobalt cardiomyopathy? When should it be suspected?
Cobalt cardiomyopathy is incredibly rare, with only a handful of reported cases. 2 It is also known as beer drinkers’ cardiomyopathy, as cobalt was added to beer for fortification in Quebec 3, where it was first reported. Cobalt cardiomyopathy is characterized by its rapidly progressive nature, the presence of low voltages on EKG, and diffuse infiltration. Patients also complained of a previous history of anorexia and weight loss and were found to have polycythemia and thyroid abnormalities on labs. This syndrome was very similar to wet beriberi except for the absence of a therapeutic response to thiamine.
Taken from - 2
Later, this was noted in patients with total metal hip arthroplasty 4–6, especially in patients with metal-on-metal hip arthroplasty, which led to corrosion and leakage of cobalt into the bloodstream. The syndrome in these patients was similar to those in beer drinkers from Quebec.
This figure, taken from 2, shows the reports of Cobalt cardiomyopathy after cobalt alloy prostheses. [HX1]
What is the pathophysiology of cobalt cardiomyopathy?
Cobalt has a variety of effects on the heart, both microscopically and biochemically.Cobalt may have multiple calcium-mediated cardiac effects and may also interfere with the Krebs cycle and ATP generation by mitochondria. Histology may show modest changes with no inflammatory response o...
391. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #35 with Dr. Mark Drazner
Sep 19, 2024
The following question refers to Section 2.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by University of Colorado internal medicine resident Dr. Hirsh Elhence, answered first by University of Chicago advanced heart failure cardiologist and Co-Chair for the CardioNerds Critical Care Cardiology Series Dr. Mark Belkin, and then by expert faculty Dr. Mark Drazner.Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the President of the Heart Failure Society of America.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #35
A 50-year-old woman with a history of congestive heart failure, hypertension, type 2 diabetes mellitus, and obstructive sleep apnea presents to the outpatient clinic to follow up on her heart failure management. One year prior, echocardiogram showed an ejection fraction of 30% with an elevated BNP, for which she was started on appropriate GDMT. Repeat echocardiogram today showed an EF of 50%. Which of the following best describes her heart failure status?
A
HFrEF (HF with reduced EF)
B
HFimpEF (HF with improved EF)
C
HFmrEF (HF with mildly reduced EF)
D
HFpEF (HF with preserved EF)
Answer #35
Explanation
The correct answer is B – HFimpEF, or heart failure with improved ejection fraction, best describes her current heart failure status.
Left ventricular ejection fraction is an important factor in classifying heart failure given differences in prognosis, response to treatment, and use in clinical trial enrollment criteria.
The classification of heart failure by EF (adopted from the Universal Definition of HF):
– HFrEF (HF with reduced EF): LVEF ≤40%
– HFimpEF (HF with improved EF): previous LVEF ≤40%, a ≥10% increase from baseline LVEF, and a second measurement of LVEF >40%.
– HFmrEF (HF with mildly reduced EF): LVEF 41%–49%, andevidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)
– HFpEF (HF with preserved EF): LVEF ≥50%, and evidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)
Patients with HFmrEF are usually in a dynamic state of improving from HFrEF or deteriorating towards HFrEF. Therefore, patients with HFmrEF may benefit from follow-up evaluation of systolic function and etiology of sub-normal EF.
Improvements in EF are associated with better outcomes but do not indicate full myocardial recovery or normalization of LV function. Indeed, structural and functional abnormalities such as LV dilation and systolic or diastolic dysfunction often persist. Moreover, EF may remain dynamic with fluctuations in either direction depending on factors such as GDMT adherence and re-exposure to cardiotoxic agents. As such, the term heart failure with “improved EF” was deliberately chosen over “recovered EF” and “preserved EF”. Importantly, in patients with HFimpEF while on GDMT, the EF may decrease after withdrawal of GDMT.
Main Takeaway
390. Cardio-Rheumatology: Deciphering Cardiovascular Risk in Patients with Rheumatologic Conditions with Dr. Brittany Weber and Dr. Michael Garshick
Sep 18, 2024
CardioNerds Cardio-Rheumatology Series Co-Chairs Dr. Rick Ferraro, Dr. Gurleen Kaur, and and Dr. Bree Hansen discuss how to decipher cardiovascular risk in patients with rheumatological conditions with cardio-rheumatology experts Dr. Brittany Weber and Dr. Michael Garshick.
In this episode, Drs. Weber and Garshick take us through the role of inflammation in patients with rheumatologic conditions and cardiovascular disease. They discuss the increased prevalence of traditional cardiac risk factors in this population and how these standard cardiac risk factors do not account for the full extent of cardiovascular risk. Dr. Bree Hansen drafted show notes. Audio editing by CardioNerds intern Christiana Dangas.
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Pearls - Cardio-Rheumatology - Deciphering Cardiovascular Risk in Patients with Rheumatological Conditions
Cardiovascular disease prevalence: cardiovascular disease is common in patients with autoimmune rheumatologic disease; therefore, we must take every opportunity to screen patients early.
Limitations of Traditional Scores: conventional risk calculators often underestimate cardiovascular risk for autoimmune disease patients, necessitating additional methods to assess risk accurately.
Integration of Disease-Specific Biomarkers: using biomarkers specific to autoimmune diseases, such as lupus, enhances risk assessment and helps in tailoring treatment strategies.
Value of Imaging and Risk Enhancers: incorporating imaging (like CAC scoring and carotid ultrasound) and evaluating additional risk factors (such as lipoprotein(a) and high-sensitivity CRP) provides a more comprehensive view of cardiovascular risk and guides more effective management.
Show notes - Cardio-Rheumatology - Deciphering Cardiovascular Risk in Patients with Rheumatological Conditions
Show notes (Drafted by Dr. Bree Hansen):
How does inflammation contribute to atherosclerosis, specifically in autoimmune rheumatologic diseases like psoriasis?
Lipids need to enter the intimal space of blood vessels, which can be facilitated by endothelial damage caused by chronic cytokine stimulation, such as TNF or IL-6. Once in the intima, lipids are recognized as foreign, leading to the recruitment of monocytes that transform into macrophages to clear these lipids. However, this process often exacerbates the problem, leading to persistent inflammation and atherosclerotic plaque formation.
Specifically, in psoriasis, the endothelial damage is particularly pronounced due to cytokines like TNF, IL-17, and interferons. The inflammasome pathway, which is highly active in psoriasis, also contributes to endothelial damage. Additionally, hyperactivated platelets in psoriasis can further damage the endothelium and contribute to atherosclerosis.
Overall, atherosclerosis results from a combination of traditional risk factors and systemic inflammation, leading to the development of cardiovascular disease.
Which traditional cardiovascular risk factors are increased in patients with rheumatologic conditions?
Patients with autoimmune diseases may be up to > three times more likely to develop cardiovascular disease, similar to the risk of type 2 diabetes; therefore, it is important to screen patients with autoimmune rheumatologic disorders for cardiovascular disease
Most common cardiovascular risk factors, such as smoking, diabetes, hypertension, and dyslipidemia, are also increased in patients with autoimmune rheumatologic disorders. Smoking, specifically, is highly prevalent in psoriasis and exhibits a dose-response relationship with psoriasis severity.
Hyperlipidemia is another common risk factor present in patients with autoimmune rheumatologic disease; however,
389. Case Report: When “Normal” Cholesterol is Not Normal: Exposing an Unusual Presentation of Familial Hypercholesterolemia – National Lipid Association
Sep 06, 2024
CardioNerds Dan Ambinder and Dr. Devesh Rai join cardiology fellows and National Lipid Association lipid scholars Dr. Jelani Grant from Johns Hopkins University and Dr. Alexander Razavi from Emory University. They discuss a case involving a patient with familial hypercholesterolemia. Dr. Archna Bajaj from University of Pennsylvania provides expert commentary. Drs. Jelani Grant and Alexander Razavi drafted notes. CardioNerds Intern Pacey Wetstein engineered episode audio.
This episode is part of a case reports series developed in collaboration with the National Lipid Association and their Lipid Scholarship Program, with mentorship from Dr. Daniel Soffer and Dr. Eugenia Gianos.
A classic finding in patients with familial hypercholesterolemia is the presence of markedly elevated levels of total and low-density lipoprotein cholesterol (LDL-C) with an LDL-C concentration of 190 mg/dL or greater. However, severe hypercholesterolemia is not inevitably present, and many patients who carry this diagnosis may have lower LDL-C levels. This case history describes a young woman whose mother and brother met clinical and genetic criteria for heterozygous familial hypercholesterolemia but who had only a mild elevation in LDL-C, falling to 130 mg/dL after dietary intervention. Despite this finding, genetic testing revealed the presence of the same genetic variants as were noted in her mother and brother. In addition, a second genetic variant predisposing them to cholesterol gallstone formation was identified in all three family members. If genetic testing had not been performed, the diagnosis may have been missed or delayed, resulting in an increased risk for vascular complications associated with familial hypercholesterolemia. This case supports the value of genetic testing of family members of those with familial hypercholesterolemia, even when LDL-C levels are not severely elevated.
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Pearls - Exposing an Unusual Presentation of Familial Hypercholesterolemia – National Lipid Association
Familial hypercholesterolemia (FH) is among the most common autosomal co-dominant genetic conditions (approximately 1:200 to 1:300 for HeFH, 1:160,000 to 1:300,000 for HoFH).
Genetic testing has a role for all first-degree relatives when a family history of FH is strongly suggestive, regardless of LDL-C level.
Heterogeneity in ASCVD risk among individuals with FH is derived from background polygenic risk, clinical risk factors (e.g., timing of lipid-lowering initiation and adjacent risk factors), as well as subclinical atherosclerosis burden.
In clinical or genetically confirmed FH, an LDL-C goal of 55 mg/dL is recommended.
Beyond statins, FDA-approved non-statin therapies for FH include ezetimibe, PCSK9 mAb, bempedoic acid, inclisiran, evolocumab (only HoFH), lomitapide (only HoFH), and LDL apheresis.
Notes - Exposing an Unusual Presentation of Familial Hypercholesterolemia – National Lipid Association
What are the diagnostic criteria for FH?
Dutch Lipid Clinic Network1
Variables: family history, clinical history, physical exam, LDL-C level, DNA (LDLR, APOB, PCSK9)
Simon-Broome1
Variables: total or LDL-C, physical exam, DNA (LDLR, APOB, PCSK9), family history
Emphasis on clinical history and physical exam reduces sensitivity
U.S. Make Early Diagnosis Prevent Early Death (MEDPED) 1
Only one of the three where no genetic testing is required, may work well in cascade screening
Variables: age, total cholesterol, family relative (and degree) with FH
Definite, probable, possible, unlikely
Emphasis on clinical history and physical exam reduces sensitivity
388. Ironing out the Data: Iron Deficiency in Heart Failure with Dr. Robert Mentz
Aug 20, 2024
CardioNerds Cofounder Dr. Amit Goyal, Chair of the CardioNerds Heart Failure Committee Dr. Jenna Skowronski, and Episode FIT Lead Dr. Shazli Khan discuss iron deficiency and its impact on heart failure with Dr. Robert Mentz, Chief of Heart Failure at Duke University and principal investigator of the HEART-FID trial. In this case-based discussion, they cover the diagnostic criteria of iron deficiency in heart failure, epidemiology, and strengths and limitations of different iron formulations. They also review clinical trials examining the impact of iron deficiency on quality of life, heart failure hospitalizations, and mortality. Importantly, they stress the relevance of iron metabolism in heart failure, irrespective of the presence of anemia. They also discuss the approach to addressing outpatient management of iron in heart failure and future directions of research needed in this domain.
Notes were drafted by Dr. Shazli Khan, and Dr. Daniel Ambinder engineered episode audio.
Click here for CME.
This episode was created in collaboration with the Cardiometabolic Health Congress and is supported by an educational grant from American Regent. Please follow the link in the show notes for free CME. All CardioNerds education is planned, produced, and reviewed by CardioNerds.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Pearls - Iron Deficiency in Heart Failure
Think about iron deficiency in ALL patients with heart failure and send appropriate diagnostic labs, even if there is no evidence of anemia!
Iron deficiency in heart failure has a specific and distinguished definition, defined as a ferritin level of <100 ng/mL, or a ferritin level between 100-300 ng/mL with a transferrin saturation of <20%.
Data thus far suggests that treatment of iron deficiency in heart failure results in improved quality of life, as well as a probable reduction in heart failure hospitalizations, and that administration of intravenous iron has a favorable safety profile.
Not all formulations of iron are created equal – intravenous iron formulations have been shown to be effective in this population, but oral iron therapy has not.
Management of iron deficiency in the outpatient setting is an evolving area of research, but patients should typically receive surveillance labs and additional treatment with IV iron if indicated.
Show notes - Iron Deficiency in Heart Failure
How is iron deficiency in heart failure defined, and how prevalent is iron deficiency in this patient population?
Iron deficiency is common in patients with heart failure, with an estimated prevalence of 50-60%.Iron deficiency in heart failure is associated with worse outcomes, including increased hospitalization and mortality and poorer functional status and quality of life.Iron deficiency in heart failure is defined as a ferritin level of <100 ng/mL or a ferritin level of 100-300 ng/mL plus a transferrin saturation of <20%.
There is an evolving school of thought that suggests transferrin saturation alone may be the best indicator of iron deficiency in heart failure, but more data are needed.
Importantly, iron deficiency in heart failure can be seen in patients with both reduced and preserved ejection fraction. Which patients should be screened for iron deficiency?
There is a class I indication to send iron studies in all patients with heart failure as a part of the initial diagnostic work-up for the underlying etiology of the cardiomyopathy, as well as to assess for the presence of iron deficiency.The presence of anemia is not required to check iron studies, as many patients with iron deficiency in heart failure may not have conc...
387. Cardio-Rheumatology: The Role of Inflammation in Cardiovascular Disease with Dr. Antonio Abbate
Aug 18, 2024
CardioNerds Cardio-Rheumatology Series Co-Chairs Dr. Rick Ferraro, Dr. Gurleen Kaur, and Episode Lead Dr. Ronaldo Correa discuss “The Role of Inflammation in Cardiovascular Disease” with Dr. Antonio Abbate.
Join the CardioNerds as they kick off the Cardio-Rheumatology series with Dr. Antonio Abbate. In this episode, Dr. Abbate, a leading expert in cardio-immunology, discusses the role of inflammation in cardiovascular disease. We explore the molecular mechanisms linking inflammation to atherosclerosis, the impact of chronic low-grade systemic inflammation on heart disease, and potential therapeutic targets. Dr. Abbate shares insights on how genes and lifestyle factors contribute to inflammation, the use of inflammatory markers in clinical practice, and emerging anti-inflammatory therapies in atherosclerotic cardiovascular disease. Tune in for an enlightening conversation on the intersection of inflammation and cardiovascular health.
Dr. Ronaldo Correa drafted the notes. Episode audio was engineered by Dr. Amit Goyal.
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Pearls - Cardio-Rheumatology: The Role of Inflammation in Cardiovascular Disease
Inflammation is key in the pathogenesis and progression of atherosclerosis. Estimating systemic inflammation is part of a comprehensive preventive assessment (primary/secondary).
Patients with autoimmune inflammatory diseases are at a higher risk for cardiovascular events.
C-reactive protein (CRP) can estimate systemic inflammation and help assess residual inflammatory risk in patients with traditional intermediate/low cardiovascular disease, guiding management consideration with lipid-lowering therapy, aspirin, and colchicine.
The pharmacological management of atherosclerosis is evolving beyond primarily lipid-lowering therapies to focus on targeting the underlying residual inflammatory process. Colchicine (inflammasome blocker as an anti-mitotic drug) is approved for use in chronic stable CVD in selected cases, and interleukin pathway blockers, especially IL-1 and IL-6, are under clinical trial investigation.
First things first! Prioritize treating and optimizing traditional risk factors and comorbidities and emphasize lifestyle modifications to reduce cardiovascular disease (control diabetes and hypertension, reduce or cease smoking/alcohol, lose weight, and engage in regular physical activity). They all impact inflammation directly or indirectly
Show notes - Cardio-Rheumatology: The Role of Inflammation in Cardiovascular Disease
Notes: Notes drafted by Dr. Ronaldo Correa.
What is the link between inflammation and cardiovascular atherosclerosis?
Inflammation is involved both in the pathogenesis and progression of atherosclerosis.Histopathological coronary atherosclerosis studies have demonstrated the presence of inflammatory mediators as well as a central role of factors of innate immunity such as macrophages and T cells which can interact with vascular smooth muscle cells in the progression of atherosclerotic plaque.Patients with autoimmune inflammatory conditions have earlier and higher cardiovascular event rates (accelerated atherosclerosis due to residual inflammatory risk).
Elevated inflammatory markers (for example, high CRP) predict cardiovascular events.
How should inflammation be considered in the context of residual cardiovascular risk?
Inflammation may be the inciting factor in atherosclerosis, or it may amplify the process driven primarily by other risk factors. Therefore, treating the comorbidities and traditional CVD contributors is key to reducing the vicious inflammatory cycle.Assessing residual risk using inflammatory markers can assist in management. C-reactive protein (CRP) can estimate systemic inflammation and help assess re...
386. Beyond the Boards: Cardiomyopathies with Dr. Steve Ommen
Aug 16, 2024
CardioNerds (Drs. Teodora Donisan, Jenna Skowronski, and Johnny Hourmozdi) discuss Cardiomyopathies with Dr. Steve Ommen. Through a case-based discussion, we review the diagnostic evaluation of suspected restrictive cardiomyopathy, and Dr. Ommen shares his expertise in the nuances of caring for patients with hypertrophic cardiomyopathy, from counseling to pharmacologic, device, and septal reduction therapies. We cover the foundations of diagnosis and management that will be helpful to CardioNerds preparing to encounter hypertrophic cardiomyopathy on the boards or on the wards.
Dr. Johnny Hourmozdi drafted notes. The audio was engineered by Dr. Atefeh Ghorbanzadeh.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
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Pearls and Quotes - Cardiomyopathies
The presence of an S4 and a rapid y-descent in the jugular venous pulsation on exam should clue you to the presence of a restrictive filling pattern. Restrictive filling doesn’t necessarily mean restrictive cardiomyopathy and is more commonly due to dilated or ischemic cardiomyopathy.
The five main topics of counseling that every hypertrophic cardiomyopathy (HCM) patient should understand: (1) Prognosis, (2) Family Screening, (3) Risk of Sudden Death, (4) Treatments, and (5) Physical Activity.
Remember 1/3: In clinical trials of cardiac myosin inhibitors for HCM (mavacamten), about a third of patients had a tremendous improvement in symptoms, another third had some improvement, and the final third had no improvement or had to discontinue the drug due to negative inotropy.
When counseling patients about septal reduction therapy, consider the patient’s age. For younger patients, surgical myectomy at an experienced center offers a higher success rate and greater durability with lower rates of pacemaker placement when compared to alcohol septal ablation.
Historically, the conclusion that it was higher risk to be an athlete with HCM was unfortunately generalized to mean that it was high risk to exercise for patients with HCM. “And we turned a generation of HCM patients into HCM cardiometabolic syndrome patients, which is actually a worse combination.”
Notes - Cardiomyopathies
What is the initial approach to evaluating a patient with new or suspected cardiomyopathy, including hypertrophic cardiomyopathy (HCM)?
A history and physical exam, including a thorough past medical and family history, is always the first step and helps determine the patient’s risk for potential underlying etiologies, including genetic cardiomyopathies, hypertrophic cardiomyopathy, or those related to treatments of previous cancer.
In terms of ECG findings, pay attention to QRS voltage (high or low) and the presence of any arrhythmias.
TTE should be obtained in all patients and is often sufficient to diagnose many underlying cardiomyopathies, including HCM.
Cardiac MRI (CMR) is helpful as an adjunct when TTE alone is inconclusive or imaging quality is poor. CMR can help provide a better idea of chamber sizes and wall thickness, and late gadolinium contrast enhancement (LGE) can also be helpful if present in a specific pattern, though often HCM patients may have non-specific patterns of LGE.
Invasive hemodynamics assessment is reserved for patients with discordance between non-invasive testing and the clinical impression. It can also be useful to guide the management of heart failure, especially in advanced disease.
How do you treat patients with hypertrophic obstructive cardiomyopathy (HOCM)?
In patients with HCM and LVOT obstruction (defined a...
385. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #34 with Dr. Mark Drazner
Aug 09, 2024
The following question refers to Sections 6.1 and 7.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by University of Colorado internal medicine resident Dr. Hirsh Elhence, answered first by University of Chicago advanced heart failure cardiologist and Co-Chair for the CardioNerds Critical Care Cardiology Series Dr. Mark Belkin, and then by expert faculty Dr. Mark Drazner.
Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the President of the Heart Failure Society of America.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #34
Question StemA 72-year-old woman with a history of hypertension, type 2 diabetes mellitus, and a recent myocardial infarction is seen in your clinic. Two months previously, she was hospitalized with a myocardial infarction and underwent successful revascularization of the left anterior descending artery with a drug-eluting stent. Following her myocardial infarction, an echocardiogram revealed an ejection fraction of 17%, and she was discharged on metoprolol succinate, lisinopril, spironolactone, and dapagliflozin with escalation to maximal tolerated doses over subsequent visits. A repeat echocardiogram performed today in your clinic reveals an ejection fraction of 26%. An electrocardiogram reveals normal sinus rhythm with a narrow QRS at a heart rate of 65 beats per minute. She is grateful for her cardiac rehabilitation program and reports no ongoing symptoms. Which of the following devices is indicated for placement at this time?Answer choicesAImplantable loop recorderBICDCCRT-DDCRT-P
Answer #34
Explanation The correct answer is B.This patient suffered a myocardial infarction more than 40 days ago and has been on appropriate guideline-directed medical therapy since that time. Her left ventricular ejection fraction has improved but remains under 30%. For patients who have suffered a myocardial infarction over 40 days prior with LVEF ≤ 30% and NYHA Class I symptoms while receiving GDMT and have a reasonable expectation of meaningful survival for >1 year, an ICD is recommended for primary prevention of sudden cardiac death to reduce total mortality (Class I, LOE B-R).The MADIT-II trial enrolled 1,232 patients with a prior myocardial infarction and LVEF ≤ 30% to prophylactic ICD or medical therapy. At a median follow-up of 20 months, the trial was terminated early for reduced all-cause mortality with prophylactic ICD. The DINAMIT trial later investigated the implantation of ICD in patients with MI and an LVEF of ≤ 35% at 6 to 40 days after the initial myocardial infarction. This trial found no differences in all-cause mortality between the two groups. Therefore, the current recommendation is to wait at least 40 days with GDMT prior to re-evaluation of left ventricular ejection fraction before proceeding with ICD implantation.Cardiac resynchronization therapy entails implanted pacemakers to simultaneously pace both the RV and LV in order to improve electrical synchrony and generally provides benefit in those with systolic dysfunction and a wide left bundle branch block. Specifically, for patients who have LVEF ≤35%, sinus rhythm,
384. Case Report: Little (a), Big Deal – National Lipid Association
Aug 07, 2024
CardioNerds Dan Ambinder and Dr. Devesh Rai join cardiology fellows and National Lipid Association lipid scholars Dr. Oby Ibe from Temple University and Dr. Elizabeth Epstein from Scripps Clinic. They discuss a case involving a patient with elevated Lp(a). Dr. Jessica Pena provides expert commentary. Drs. Oby Ibe and Elizabeth Epstein drafted notes. CardioNerds Intern Christiana Dangas engineered episode audio. This episode is part of a case reports series developed in collaboration with the National Lipid Association and their Lipid Scholarship Program, with mentorship from Dr. Daniel Soffer and Dr. Eugenia Gianos.
An asymptomatic 34-year-old female presented to the cardiology clinic for cardiovascular risk assessment. Her past medical history included polycystic ovarian syndrome (PCOS) and depression. Her labs were notable for total cholesterol 189 mg/dL, LDL of 131 mg/dL, HDL 34 mg/dL, triglycerides 134 mg/dL, and Lp(a) 217 nmol/L. Her 10-year ASCVD risk by the PREVENT calculator was 0.5%, and her 30-year risk was 3.5%. She had no carotid plaque. Because her 30-year risk was significantly increased by her elevated Lp(a), intensive risk factor management was emphasized, and she was started on a low-dose statin with a plan to follow the patient to reassess the need for intensification of lipid-lowering and/or initiation of novel Lp(a)-lowering therapies over time.
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Pearls - Little (a), Big Deal – National Lipid Association
You are never too young to see a preventive cardiologist! The field of preventive cardiology is shifting focus towards the identification of early upstream risk and intervention before the development of clinical ASCVD (1,5). Patients who have a strong family history of cardiovascular disease, a personal history of CVD at an early age, multiple risk factors, or genetic disorders such as familial hypercholesterolemia especially benefit from early cardiovascular risk assessment and reduction.
Female-specific risk factors to incorporate into a young woman’s cardiovascular risk assessment include polycystic ovarian syndrome, hormone contraceptive use, early menarche (age <10 years old), primary ovarian insufficiency, fertility therapy, hypertensive disorders of pregnancy (eclampsia, preeclampsia, gestational hypertension, preterm delivery, gestational diabetes, multi-parity >5 pregnancies), early menopause (age <45 years old), & post-menopausal hormone therapy.
Lp(a) testing for all! The most recent NLA scientific statement on the use of Lp(a) in clinical practice recommends measuring Lp(a) at least once in every adult for risk stratification.
While Lp(a) has not yet been incorporated into our risk calculators, we do know that elevated Lp(a) increases 10-year risk. The European Atherosclerosis Society published a consensus statement on Lp(a), which includes a handy table to quantify the degree to which a patient’s 10-year risk increases as Lp(a) increases.
Lifestyle changes are the first line and can reduce the risk of high Lp(a) by 66%. Next, we can consider the risks and benefits of LDL-lowering in a young patient and monitor closely for the development of plaque over time. Lp(a) lowering drugs such as olpasiran are on the horizon, and we can keep this patient in mind as a potential candidate for therapy in the future.
Notes - Little (a), Big Deal – National Lipid Association
When should patients see a preventive cardiologist?
Strong family history of cardiovascular disease – A positive family history of CVD was defined as a self‐reported diagnosis of CVD in parents, siblings, or children that occurred at 60 years or younger.
383. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #33 with Dr. Biykem Bozkurt
Jul 30, 2024
The following question refers to Section 5.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by University of Colorado internal medicine resident Dr. Hirsh Elhence, answered first by advanced heart failure faculty at the University of Chicago and Co-Chair for the CardioNerds Critical Care Cardiology Series Dr. Mark Belkin, and then by expert faculty Dr. Biykem Bozkurt.Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, and current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Question #33
A 63-year-old man with a past medical history of hypertension and type 2 diabetes mellitus presents for routine follow-up. He reports feeling in general good health and enjoys 2-mile walks daily. A review of systems is negative for any symptoms. Which of the following laboratory studies may be beneficial for screening?ANT-proBNPBCK-MBCTroponinDC-reactive proteinENone of the above
Answer #33
ExplanationThe correct answer is A – NT-proBNP.This patient is at risk for HF (Stage A) given the presence of risk factors (hypertension and type 2 diabetes mellitus) but the absence of signs or symptoms of heart failure.Patients at risk for HF screened with BNP or NT-proBNP followed by collaborative care, diagnostic evaluation, and treatment in those with elevated levels can reduce combined rates of LV systolic ...
382. SGLT Inhibitors: The Data Supporting SGLT Inhibition with Dr. Muthiah Vaduganathan
Jul 28, 2024
CardioNerds Dr. Rick Ferraro, Dr. Gurleen Kaur, and Dr. Maryam Barkhordarian discuss the evidence and data supporting SGLT inhibition for cardiovascular and kidney health outcomes with expert faculty Dr. Muthu Vaduganathan. They discuss the role of SGLT inhibitors in different populations, including those with diabetes mellitus, heart failure, CKD, and myocardial infarction. Show notes and audio editing by CardioNerds Academy Fellow Dr. Maryam Barkhordarian.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals.
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Pearls - The Data Supporting SGLT Inhibition with Dr. Muthiah Vaduganathan
The benefit of SGLT inhibition extends beyond diabetes, and improves cardiovascular and kidney health outcomes independent of diabetes in appropriate patient populations.
SGLT inhibition decreases cardiovascular mortality and heart failure hospitalization independent of left ventricular ejection fraction.
SGLT inhibitors reduce clinically relevant events such as dialysis and transplantation in CKD patients irrespective of etiology and are now a cornerstone for the prevention of CKD progression.
The introduction of polypills in heart failure can simplify GDMT implementation.
Show notes - The Data Supporting SGLT Inhibition with Dr. Muthiah Vaduganathan
How did SGLT inhibitors transition from “diabetes medication” to guideline-directed cardiovascular medicine?
Most therapies in cardiology were developed for a particular purpose and ended up being indicated for a vastly different reason. The SGLT-2 inhibitors are no different.
Cardiovascular safety concerns about diabetes medications led to a mandate to conduct cardiovascular outcomes trials for all novel diabetes medications. This federal requirement shed light on the cardiovascular benefits of SGLT inhibitors in patients with diabetes.
These initial trials showed that not only are these medications safe but also, surprisingly, proved their role in preventing heart failure and delaying progression of chronic kidney disease.
What are the mechanisms of action of SGLT-2 and SGLT-1/2 inhibitors?
The central mechanism(s) of how these medications confer health outcomes benefits patients is/are not well understood.
The main organ involved in the action of SGLT-2 inhibitors is the kidney at the level of the proximal tubule, impacting the cardiovascular system by handling salt and water and improving kidney efficiency. Conversely, SGLT-1/2 inhibitors also act at the level of the gut, the predominant location of the SGLT-1 cotransporter.
Their effects on the cardiovascular system are secondary, given there is no SGLT-1 or -2 cotransporters in the myocardium. These secondary effects can be impacted through blood pressure reduction, volume regulation, improved glycemic control, etc. to overall improve cardiovascular status.
Whatever the underlying mechanisms, the empirical data for their use is strong and growing.
What is the role of SGLT inhibitors in preventing CKD progression?
RAAS inhibitors (ACE inhibitors and ARBs) have been the cornerstone of CKD management for the past two to three decades.
SGLT inhibitors have been the first add-on to this background therapy.
Four trials, DAPA-CKD, EMPA-CKD, CREDENCE, and the SCORED, investigated the effects of SGLT-2 and SGLT-1/2 inhibitors in patients with CKD with or without diabetes.
The outcomes of these trials include modifying the course of CKD and reducing events such as dialysis initiation and transplantation. These effects were regardless of participants’ diabetic status, CKD etiology, or individual patient profile.
381. Narratives in Cardiology: Advocacy for Refugee Health and Empowering First-Generation Cardiologists with Dr. Heval Kelli
Jul 19, 2024
In this episode, Dr. Gurleen Kaur (Cardiology FIT at Brigham and Women’s Hospital and APD of the CardioNerds Academy) and Dr. Chelsea Amo-Tweneboah (Medicine Resident at Stonybrook and CardioNerds Academy Intern) discuss with Dr. Heval Kelli (Cardiologist at Northside Hospital Cardiovascular Institute) about his personal and professional journey in Cardiology. They discuss Dr. Kelli’s lifelong advocacy for serving those in need including refugee and immigrant communities, his character in the documentary Refuge, and fostering inclusivity within Cardiology. Audio editing and show notes were drafted by Dr. Chelsea Amo-Tweneboah.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
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Video version - Advocacy for Refugee Health and Empowering First-Generation Cardiologists
https://youtu.be/hP8bLt9q2sY
Quoatables - Advocacy for Refugee Health and Empowering First-Generation Cardiologists
“I have always believed that if someone opened the door for you, you have to hold the door for the next generation. Because if you just walk through the door and close it, you just close the door for many people behind you.”
“Instead of making luck a matter of luck, just make an opportunity for everyone else.”
“Hate makes us realize that no matter how privileged you are, you are not protected.”
“It is very hard to hate something you know.”
“Compassion starts with the neighbor next to you, and then you go out to the world and show it.”
“Your best intern wasn’t the smartest intern. Your best intern was the person ready to go for rounds, took care of everything, sharp early in the morning, stays late, and gets the work done.”
“Intelligence is relative. Hard work and dedication [are] the most important thing.”
Notes - Advocacy for Refugee Health and Empowering First-Generation Cardiologists
Advocacy for refugee health and empowering first-generation cardiologists
Focusing on creating professionals from a given community can help increase their chances of returning to that community and helping to address health disparities.
Refugees and immigrants come from countries and communities where, by and large, prevention is lacking. Seeing a healthcare provider is more appropriate in dire situations.
When approaching immigrants, it is important to present medical information in ways in which they can understand and absorb properly.
For many refugee families, there exists a language barrier and the children are most often the advocates for the family because they are most likely to understand the language of the community they live in.
The vast number of students in the US medical school system come from privileged backgrounds; however, this same statistic is not true for the populations they end up serving.
It is important to have health professionals reflect the populations they serve, and one of the methods to achieve this is through introducing as many individuals as possible to the field of medicine; one of the ways to overcome a leaky pipeline is to pack the pipeline. Strategies include encouraging medical students to serve as ...
380. Case Report: Tearing Up My Heart – A Case of Papillary Muscle Rupture – University of Rochester
Jul 12, 2024
CardioNerds co-founder Dan Ambinder joins Dr. Lefan He, Dr. Sina Salehi Omran, and Dr. Neil Gupta from the University of Rochester Cardiovascular Disease Fellowship Program for a day sailing on Lake Ontario. Expert commentary is provided by Dr. Jeffrey Bruckel, and CV Fellowship Program Director Dr. Burr Hall shares insights on the University of Rochester fellowship. The episode audio was edited by CardioNerds intern Dr. Atefeh Ghorbanzadeh. They discuss the following case involving a patient with papillary muscle rupture.
This is a 63-year-old man with hypertension, hyperlipidemia, and active tobacco smoking who presented with acute dyspnea. He was tachycardic but otherwise initially hemodynamically stable. The physical exam demonstrated warm extremities with no murmurs or peripheral edema. Chest X-ray revealed diffuse pulmonary edema, and the ECG showed sinus tachycardia with T-wave inversions in the inferior leads. A bedside echocardiogram revealed a flail anterior mitral valve leaflet. The patient was taken for cardiac catheterization that revealed nonobstructive mid-RCA atheroma with a distal RCA occlusion, which was felt to reflect embolic occlusion from recanalized plaque. PCI was not performed. Right heart catheterization then demonstrated a low cardiac index as well as elevated PCWP and PA pressures. An intra-aortic balloon pump was placed at that time. A TEE was performed soon after which showed the posteromedial papillary muscle was ruptured with flail segments of the anterior mitral leaflet as well as severe posteriorly directed mitral regurgitation. The patient ultimately underwent a successful tissue mitral valve replacement and CABG.
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case Media
Pearls - A Case of Papillary Muscle Rupture
Most cases of papillary muscle rupture demonstrate only small areas of ischemia with preserved ventricular function, thus causing high shear force on the ischemic papillary muscle.
The posteromedial papillary muscle has a single blood supply from the posterior descending artery, while the anterolateral papillary muscle has a dual blood supply from the LAD and the circumflex. Therefore, the posteromedial papillary muscle is more vulnerable to ischemia and, hence, rupture.
A murmur may be absent in cases of papillary muscle rupture due to the rapid equalization of left atrial and left ventricular pressures caused by the acuteness of the severe MR. Papillary muscle rupture should always be on the differential for acute dyspnea when ACS is suspected.
While mostly associated with STEMIs, mechanical complications of acute myocardial infarctions can also occur after NSTEMIs. Always auscultate patients carefully after a myocardial infarction!
When evaluating patients with chest pain presenting with acute or rapidly progressive heart failure and a hypercontractile LVEF should raise suspicion for mechanical complications of MI.
Once a papillary muscle rupture is diagnosed, cardiac surgery should be immediately contacted. Temporizing measures prior to surgery include positive pressure ventilation, IV nitroglycerin/nitroprusside, and temporary mechanical circulatory support.
Notes - A Case of Papillary Muscle Rupture
What is the clinical presentation of acute mitral regurgitation from papillary muscle rupture?
Patients typically present 3-5 days after a transmural infarct. Roughly half of these patients present with pulmonary edema that may quickly progress to cardiogenic shock.
Most cases are associated with STEMIs, but papillary muscle rupture is also possible with an NSTEMI.
379. SGLT Inhibitors: The Biology of SGLT Inhibition with Dr. Katherine Tuttle
Jul 09, 2024
CardioNerds (Drs. Gurleen Kaur and Richard Ferraro) and episode FIT Lead Dr. Saahil Jumkhawala (Cardiology Fellow at the University of Miami) discuss SGLT inhibitors, focusing on the biology of SGLT and its inhibition, with Dr. Katherine Tuttle (Executive Director for Research at Providence Healthcare, Co-Principal Investigator of the Institute of Translational Health Sciences, and Professor of Medicine at the University of Washington). Show notes were drafted by Dr. Saahil Jumkhawala. The episode audio was engineered by CardioNerds intern Christiana Dangas.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Lexicon Pharmaceuticals.
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Pearls - The Biology of SGLT Inhibition with Dr. Katherine Tuttle
SGLT inhibitors, while initially developed as antidiabetic medications, have been shown to be beneficial for cardiovascular and renal outcomes. These benefits result from their on-target glucosuric effects and additional off-target effects.
The side effect profiles of SGLTis are primarily mediated by glucose reabsorption in their target tissues. The side effect profile of SGLTis must be considered when prescribing these medications and is generally favorable for SGLT2is versus SGLT1is.
Once SGLTis are prescribed, patients should be given specific attention to their eGFR, serum potassium, and clinical evaluations of volume status and blood pressure.
Strategies to increase implementation of and reduce clinical inertia for these important class of medication remain an area of active investigation
Show notes - The Biology of SGLT Inhibition with Dr. Katherine Tuttle
What should prompt consideration of starting an SGLT inhibitor?
Considerations for SGLT inhibitor initiation are based on a history of heart failure, kidney disease, and diabetes status.
In the EMPA-KIDNEY trial, empagliflozin improved cardiovascular and kidney outcomes in those with low GFR (regardless of level of albuminuria).
What is the mechanism of action of SGLT2 inhibitors?
SGLT2 inhibitors improve glycemic control by blocking SGLT2 receptor-mediated reabsorption of glucose in the proximal convoluted tubule, where 80-90% of this reuptake occurs, and increased downstream excretion of glucose and sodium chloride. SGLT2 inhibitors provide only a modest glucose-lowering effect, particularly for patients with GFR <45.
How do SGLT2 inhibitors improve cardiac function?
Through corrected glomerular hyperfiltration, there is a reduction in blood pressure, a reduction in sympathetic neural activity, and increased glucosuria, improving diuresis. Systemically, there is an increase in erythropoietin, which raises red blood cell mass and oxygen-carrying capacity.Beyond inhibition of the SGLT2 receptor, which is isolated to the proximal convoluted tubule, there are additional off-target effects. Through non-receptor-mediated mechanisms, glucose transport is blocked into cells by blocking GLUT1 and GLUT4 receptors. They also reduce the mTORC signal transduction pathway, thereby reducing inflammation and glycolysis, leading to a cardioprotective effect in myocytes.In the DAPA-CKD and CREDENCE trials, GFR decreases of up to 30% were correlated with improved renal and cardiovascular outcomes.
The cardiovascular benefit of SGLT2 inhibitors is not dose-dependent.
Where are SGLT1 receptors located?
SGLT1 receptors are found primarily in small and large bowel enterocytes, as well as the kidney proximal tubule, beyond the convoluted segment.
Around 10% of glucose re-uptake is mediated by SGLT1 receptors in the proximal tubule.
What are some common side effects of SGLT inhibitors?
378. Case Report: Severe Mitral Paravalvular Regurgitation Complicated by Hemolytic Anemia – Duke University
Jun 26, 2024
CardioNerds cofounder, Amit Goyal joins Dr. Belal Suleiman, Dr. Nkiru Osude, and Dr. David Elliott from Duke University. They discuss a case of severe mitral paravalvular regurgitation complicated by hemolytic anemia. Expert commentary is provided by Dr. Andrew Wang. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.
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Case Media - Severe Mitral Paravalvular Regurgitation Complicated by Hemolytic Anemia - Duke University
377. CardioOncology: Multi-modality Imaging in Cardio-Oncology with Dr. Nausheen Akhter
Jun 24, 2024
CardioNerds Co-Founder Dr. Daniel Ambinder, Series Co-Chair Dr. Giselle Suero Abreu (FIT at MGH), and Episode Lead Dr. Iva Minga (FIT at the University of Chicago) discuss the use of multi-modality cardiovascular imaging in cardio-oncology with expert faculty Dr. Nausheen Akhter (Northwestern University). Show notes were drafted by Dr. Sukriti Banthiya and episode audio was edited by CardioNerds Intern and student Dr. Diane Masket.
They use illustrative cases to discuss:
Recommendations on the use of multimodality imaging, including advanced echocardiographic techniques and cardiac MRI, in patients receiving cardiotoxic therapies and long-term surveillance.
Role of nuclear imaging (MUGA scan) in monitoring left ventricular ejection fraction.
Use of computed tomography to identify and/or monitor coronary disease.
Imaging diagnosis of cardiac amyloidosis.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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References - Multi-modality Imaging in Cardio-Oncology
Baldassarre L, Ganatra S, Lopez-Mattei J, et al. Advances in Multimodality Imaging in Cardio-Oncology. J Am Coll Cardiol. 2022 Oct, 80 (16) 1560–1578.
376. Case Report: Tamponade or Cardiovascular Support? A case of Pericardial Decompression Syndrome – University of Michigan
Jun 21, 2024
CardioNerds cofounders, Dan Ambinder joins Drs. Aishwarya Pastapur, Oyinkansola Osobamiro, and Rafik Issa from the University of Michigan for drinks in Ann Arbor. They discuss the following case of pericardial decompression syndrome. Expert commentary is provided by Dr. Brett Wanamaker. Notes were drafted by Dr. Aishwarya Pastapur and Dr. Rafik Issa. The episode audio was engineered by CardioNerds Intern student Dr. Atefeh Ghorbanzadeh.
A woman in her 50s with a past medical history of stage IV lung cancer (with metastatic involvement of the liver, bone, and brain), previous saddle pulmonary emboli, pericardial effusion, and malignant pleural effusions presents with dyspnea. She was found to have a pericardial effusion with tamponade physiology relieved by pericardiocentesis. We discuss the management of cardiac tamponade, indications for pericardiocentesis, how to monitor for post-pericardiocentesis complications, and what to keep on your differential diagnosis for decompensation after pericardiocentesis. We discuss the epidemiology, pathophysiology, diagnosis, and management of pericardial decompression syndrome.
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Case Media - Pericardial Decompression Syndrome
Pearls - Pericardial Decompression Syndrome
Diminished heart sounds, a low-voltage EKG with electrical alternans, elevated jugular venous pressure/pulsations (JVP), and the presence of pulses paradoxes are important findings that could suggest tamponade.
McConnell sign is strongly concerning for right ventricular failure and pulmonary hypertension, potentially due to acute pulmonary embolism.
Mechanical thrombectomy for pulmonary embolism is not feasible if the emboli are diffusely scattered without a central lesion to target.
For patients who experience decompensation following pericardiocentesis, consider perforation, tamponade re-accumulation, or pericardial decompression syndrome (PDS).
When possible, avoid draining more than 1L of pericardial fluid at once to minimize the risk of PDS.
Notes - Pericardial Decompression Syndrome
What is Pericardial Decompression Syndrome (PDS), and how does it present?
Pericardial decompression syndrome is a rare, life-threatening syndrome occurring in about 5-10% of cases with paradoxical worsening of hemodynamics after pericardial drainage.
The clinical presentation ranges from pulmonary edema to cardiogenic shock to death, occurring a few hours to days after a successful pericardiocentesis.
What is the underlying mechanism for PDS?
The pathophysiology behind PDS is debated, but there are three proposed mechanisms:
Paradoxical Hemodynamic Derangement: After pericardiocentesis, venous return to the RV rapidly increases, resulting in RV expansion and potentially septal deviation towards the LV. Subsequently, the LV experiences decreased preload while still facing increased afterload as a compensatory response to obstructive shock, leading to decompensation.Myocardial Ischemia: Increased intrapericardial pressure may impair coronary perfusion, leading to myocardial ischemia. Upon pericardiocentesis, there is myocardial stunning with increased demand due to increased venous return and cardiac output
Sympathetic Withdrawal: Withdrawal of sympathetic activation after drainage of pericardial fluid can trigger cardiovascular collapse
What are the risk factors for developing PDS, and how can we mitigate those risks for prevention?
Generally, patients with long-standing pericardial effusion with chronic compression of the heart, such as those with malignant pericardial effusions, are more vulnerable to developing PDS after pericardioc...
375. Beyond the Boards: Foundations of Cardiovascular Prevention with Dr. Stephen Kopecky
Jun 06, 2024
CardioNerds (Amit Goyal and Dan Ambinder), Dr. Jaya Kanduri, and Dr. Jason Feinman discuss foundations of cardiovascular prevention with Dr. Stephen Kopecky. In this episode, the CardioNerds and topic expert Dr. Stephen Kopecky tackle cardiovascular prevention. They focus on how to identify patients at risk for cardiovascular disease by using the pooled cohort equation and discuss how to incorporate additional risk-enhancing factors in risk estimation. Later, they discuss the role of non-invasive imaging and testing for further patient risk stratification. Last, they discuss the appropriate pharmacologic interventions for patient care, how to determine what LDL-c to target for each patient, and how to modify your treatment modalities in response to side effects or the need for further lipid-lowering therapies.
Notes were drafted by Dr. Jason Feinman. Audio was engineered by CardioNerds Intern Christiana Dangas.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
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Pearls and Quotes - Foundations of Cardiovascular Prevention
The 2018 cardiovascular prevention guidelines indicate that a single equation, like the pooled risk equation, does not fit everyone. There are additional risk enhancers that are not factored into the pooled risk equation that can impact an individual’s risk
These factors are often conditions that increase inflammation but can also include family history, ethnicity, chronic kidney disease, metabolic syndrome, premature menopause or gestational diabetes, and rheumatologic conditions
Data from Get With The Guidelines demonstrates that the average LDL at the time of the first myocardial infarction is 105 mg/dL.
Coronary artery calcium scores or a carotid ultrasound can be used to further risk stratify patients. However, CAC is likely to be negative in young women. A CAC of zero can be used to “de-risk” some patients but should not be used to guide therapy in the setting of tobacco usage, diabetes mellitus, or familial hypercholesterolemia.
Strategies to mitigate risk include healthy lifestyle habits and selectively targeting key risk factors including LDL, hypertriglyceridemia, inflammation, and the GLP1-pathway. Upcoming medications may address elevated Lp(a).
Notes - Foundations of Cardiovascular Prevention
Notes: Notes drafted by Dr. Jason Feinman.
How do you assess an individual's risk for cardiovascular disease?
The paramount role of primary prevention is the assessment and mitigation of an individual’s risk for ASCVD event.1
The 10-year ASCVD risk calculator is a commonly used tool to assess an individual’s risk and to guide shared decision-making conversations and recommendations.2
Individuals can be characterized as having low (less than 5%), borderline (5%-7.5%), intermediate (7.5%-20%), or high (greater than 20%) risk.2
The 10-year ASCVD risk calculator has varying validation in ethnic minorities, and other risk calculators, such as the Framingham CVD risk score, may be considered in those groups.3-5
Additional risk enhancers may be used to guide recommendations for individuals at borderline or intermediate risk.1
What additional imaging testing may be beneficial in the assessment of an individual’s risk?
Individuals with intermediate or borderline risk may benefit from further non-invasive imaging to help guide therapeutic recommendations.2
Coronary artery calcification is a marker of underlying atherosclerosis, which can help to reclassify patients to be at higher risk for ASCVD events and support interventions to help lower t...
374. Case Report: Unraveling the Mystery – When Childhood Chest Pain Holds the Key to a Genetic Heart Condition – Wayne State University
May 31, 2024
This case report explores the intricacies of familial hypercholesterolemia (FH), delving into its genetic basis, atherosclerotic cascade, and early-onset cardiovascular complications. It examines established diagnostic criteria and emphasizes personalized management, including statins, novel therapies, and lifestyle modifications.
CardioNerds cofounders (Drs. Amit Goyal and Danial Ambinder) join Dr. Irfan Shafi, Dr. Preeya Prakash, and Dr. Rebecca Theisen from the Wayne State University/DMC and Central Michigan University at Campus Martius in Downtown Detroit for some holiday ice-skating! They discuss an interesting pediatric case (see case synopsis below). Dr. Luis C Afonso provides the Expert CardioNerd Perspectives & Review segment for this episode. Audio editing by CardioNerds academy intern, Pace Wetstein.
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Case Synopsis
FH, a 9-year-old female with no previous medical history, recently moved back to the US from Iraq. She presented to establish care and discuss new-onset chest pain and dyspnea. A systolic ejection murmur was noted during her initial visit to the pediatrician, prompting cholesterol testing and a cardiology referral. Testing revealed, alarming cholesterol levels (Total Cholesterol: 802 mg/dL, LDL: 731 mg/dL, Triglycerides: 123 mg/dL) prompted concern for cardiac involvement.
Due to persistent symptoms, FH was transferred to Children's Hospital of Michigan. Despite normal findings on EKG and chest x-ray, a 2/6 systolic murmur was noted. She was discharged with a cardiology clinic follow-up.
However, two days later, FH experienced severe chest pain at rest, sweating, and difficulty breathing. She was transported to Children's Hospital again, and her troponin level measured 3000, and her total cholesterol was 695 mg/dL. An echocardiogram revealed valvar and supravalvar aortic stenosis, necessitating collaboration between Pediatric and Adult cardiology teams.
CTA thorax revealed severe supravalvular stenosis, a hypoplastic right coronary artery, and significant coronary artery obstructions. Diagnostic cardiac catheterization confirmed severe aortic stenosis and coronary artery disease, leading to the decision for surgical intervention.
FH underwent the Ross operation, left main coronary artery augmentation, and right coronary artery reimplantation. Intraoperatively, atherosclerotic plaques were observed in multiple cardiac structures.
FH's recovery was uneventful, discharged on a regimen including Atorvastatin, Ezetimibe, evolocumab, and antiplatelet therapy. Persistent high LDL levels required regular plasmapheresis. Plans for evaluations in Genetics, Lipid Clinic, Endocrine, and Gastroenterology were made, potentially leading to a liver transplant assessment. Given the severity of her condition, a heart/liver transplant might be considered in the future.
Conclusion:
This case of FH highlights the complex presentation of severe aortic stenosis and coronary artery disease in a pediatric patient. Urgent diagnosis, interdisciplinary collaboration, and aggressive management were crucial. The case underscores the importance of comprehensive care for pediatric patients with rare cardiac conditions, emphasizing collaboration between specialties for optimal outcomes and long-term well-being.
Case Media
Pearls - Familial Hypercholesterolemia
Mutations in LDLR, ApoB, or PCSK9 genes disrupt LDL-C clearance, leading to a cascade of events culminating in accelerated atherosclerosis and early-onset cardiovascular complications (e.g., CAD, aortic stenosis, PAD, stroke).
Diagnosis of familial hypercholesterolemia relies on ...
373. Narratives in Cardiology: Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
May 30, 2024
In this episode, Dr. Katie Fell (General Cardiology Fellow at University of Michigan and CardioNerds Academy Fellow) and Dr. Gurleen Kaur (incoming General Cardiology fellow at Brigham and Women’s Hospital and Director of CardioNerds Internship) discuss with Dr. James Arrighi (General Cardiologist and CEO of ACGME-International) about developing as a clinician educator and the concept of competency-based education.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
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Video version - Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
https://youtu.be/xcrwnz6_9Qg
Quoatables - Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
“You really have to have a passion or a love for what you do...that’s probably responsible for most of the success one has in life” (time 4:43)
“Sub-subspecialty societies in Cardiology represent [a] great opportunity for junior faculty or even trainees to get involved, even before getting involved in ACC.” (time 5:30)
“Competency-based medical education and time variable training are not synonymous.” (time 16:43)
“As Cardiology evolves into more and more subspecialties...it begs the question... ‘Is Cardiology a primary specialty?’” (time 27:30)
“We need to think about [a] more efficient ways for training.” (time 31:55)
“As a clinician educator, there’s variety, there’s innovation!” (time 41:22)
Notes - Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
How might one develop as a clinician educator on a national level?
Junior faculty and trainees should consider taking advantage of education opportunities in various Cardiology sub-specialty societies (ex: American Society of Nuclear Cardiology, ASNC). This may include involvement in different committees. These opportunities are great ways to build connections and establish a reputation on a national level. This can help lead to other opportunities with larger national organizations (ex: ACC, AHA).
Cardiology Training Oversight
The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Internal Medicine (ABIM) both have regulatory power over Cardiology training, providing the minimum clinical experience standards for Cardiology fellowship training programs.The ACGME oversees accreditation for Cardiology fellowships.The ABIM defines the requirements for eligibility for certification of individuals. Over time, the ACGME has transitioned to placing an emphasis on quality improvement, with a particular focus on continuous programmatic improvement.
The American College of Cardiology (ACC) helps define more granular recommendations for Cardiology training programs and their curriculum.Periodically the ACC releases training guidelines for Cardiology fellowship programs, called Core Cardiovascular Training Statements, or COCATS. This document provides more contemporary, detailed, and specialty-specific recommendations for Cardiology training as compared to ACGME.While ACC has no regulatory authority over Cardiology training programs, COCATS documents provide a roadmap for program...
372. Case Report: Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia – Georgetown University
May 23, 2024
CardioNerds (Dr. Jessie Holtzman, Chair for the CardioNerds Women’s Heart Disease Committee, and Dr. Naima Maqsood, Chair for the CardioNerds Electrophysiology Committee) join Dr. Ritika Gadodia, Dr. Namratha Meda, and Dr. Tsion Aberra from the Medstar Washington Hospital Center/Georgetown University Program for the National Cherry Blossom Festival. They discuss involving a patient with Chagas cardiomyopathy. Dr. Rachel Marcus provides the Expert CardioNerd Perspectives & Review segment for this episode. Episode audio was edited by Dr. Diane Masket.
A 79-year-old male with a history of cardiomyopathy presented with recurrent ventricular tachycardia (VT) post-CRT-D placement. On arrival, the patient was in cardiogenic shock. Initial treatment with amiodarone and milrinone failed, necessitating the addition of mexiletine. Imaging was suggestive of a left ventricular ejection fraction of 20-25% with severe global hypokinesis. Prior coronary angiogram had shown nonobstructive coronary artery disease. Further non-ischemic cardiomyopathy evaluation was unrevealing. Given his El Salvadorian origins, Chagas serology results revealed Chronic Chagas Cardiomyopathy (CCM) confirmed by CDC testing. This case underscores the importance of suspecting CCM in patients with risk factors. An early diagnosis of CCM, can prevent catastrophic events (heart blocks, ventricular arrhythmias, thromboembolic events).
In summary, this case takes the learner through the journey of a patient with non-ischemic cardiomyopathy and emphasizes the importance of approaching it with a wide range of differentials.
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Case Media
Pearls - Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia
Always consider Chagas cardiomyopathy when you have a patient from Latin America who presents with non-ischemic cardiomyopathy.
Chagas cardiomyopathy is associated with an unfavorable prognosis and serves as an independent predictor of mortality.
Chagas cardiomyopathy is arrhythmogenic and requires consideration for ICD and, when appropriate, catheter based ventricular tachycardia ablation.
It is crucial to treat patients with nifurtimox and benznidazole when appropriate.
Provide screening for first-degree family members or close relatives who may have lived in the same environment.
Show Notes - Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia
What is the disease progression in Chagas disease5?
Acute Stage:Initial infection occurs through contact with infected triatomine bug feces or contaminated blood products.Symptoms may be mild or absent but can include fever, fatigue, body aches, and swelling at the injection site (chagoma).
Parasitemia is high during this stage.
Intermediate/Indeterminate Stage:The infection becomes chronic if left untreated.Many individuals enter this stage with no noticeable symptoms.Parasitemia levels decrease, but the parasite remains in the body, mainly in muscle and cardiac tissue.
This stage can last for years to decades.
Chronic Stage:Some individuals will remain asymptomatic throughout their lives.Cardiac complications (chronic Chagas cardiomyopathy) can lead to arrhythmias, congestive heart failure, and sudden death.
Digestive complications can result in enlarged esophagus (megaesophagus) and colon (megacolon), leading to difficulties in swallowing and digestion.
When do we suspect, and who do we screen, for Chagas disease?
The seroprevalence of CCM in the USA is as high as 19%16. Among patients with LVEF<50%, the rate of positive serology was 28%. Similarly,
371. Case Report: The Curious Case of Obstructive Cardiogenic Shock – Maine Medical Center
May 14, 2024
CardioNerds Dr. Josh Saef and Dr. Tommy Das join Dr. Omkar Betageri, Dr. Andrew Geissler, Dr. Philip Lacombe, and Dr. Cashel O’Brien from the Maine Medical Center in Portland, Maine to enjoy an afternoon by the famous Portland headlight. They discuss a case of a patient who presents with obstructive cardiogenic shock. Dr. Bram Geller and Dr. Jon Donnelly provide the Expert CardioNerd Perspectives & Review segment for this episode. Dr. Maxwell Afari, the Maine Medical Center cardiology fellowship program director highlights the fellowship program. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy.
This is the case of a 42 year-old woman born with complicated Tetralogy of Fallot repair culminating in a 29mm Edwards Sapiens (ES) S3 valve placement within a pulmonary homograft for graft failure who was admitted to the cardiac ICU for progressive cardiogenic shock requiring vasopressors and inotropic support. Initial workup showed lactic acidosis, acute kidney injury, elevated NT-proBNP, and negative blood cultures. TTE showed at least moderate biventricular systolic dysfunction. She was placed on furosemide infusion, blood cultures were drawn and empiric antibiotics initiated. Right heart catheterization demonstrated elevated right sided filling pressures, blunted PA pressures with low PCWP, low cardiac index, and low pulmonary artery pulsatility index. Intracardiac echocardiography (ICE) showed a large mass within the ES valve apparatus causing restrictive valve motion with a low gradient across the pulmonic valve in the setting of poor RV function. Angiography revealed a large filling defect and balloon valvuloplasty was performed with immediate hemodynamic improvement. Blood cultures remained negative, she was gradually weaned off of inotropic and vasopressor support, and discharged. Despite empiric treatment for culture negative endocarditis and ongoing anticoagulation, she was readmitted for recurrent shock one month later at which time the pulmonic mass was revisualized on ICE. A valve-in-valve transcatheter pulmonary valve (29mm ES S3) was placed to compress what was likely pannus, with an excellent hemodynamic result and no visible mass on ICE.
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Case Media
Pearls - Obstructive Cardiogenic ShocK
Tetralogy of Fallot is the most common cyanotic defect and can lead to long term complications after surgical repair including chronic pulmonary insufficiency, RV dysfunction, residual RVOT obstruction and branch pulmonary artery stenoses.
Chronic RV failure may be more indicative of a structural defect and therefore require interventional or surgical management.
Valve thrombosis, infective endocarditis and obstructive pannus formation should be considered in the differential of a patient with obstructive shock with a prosthetic valve.
Bioprosthetic pulmonic valve obstruction may be effectively managed with balloon valvuloplasty in patients who present in acute extremis but TCPV will likely provide a more lasting result.
While valvular gradients are typically assessed via echocardiography, invasive hemodynamics can serve as a critical adjunctive tool in its characterization.
Show Notes - Obstructive Cardiogenic ShocK
Notes were drafted by Drs. Omkar Betageri, Philip Lacombe, Cashel O’Brien, and Andrew Geissler.
What are the common therapies and management for Tetralogy of Fallot?
Tetralogy of Fallot is the most common cyanotic defect in children beyond the age of one year
Anatomic Abnormalities: Anterior and Superior deviation of the conal septum creating a SubAo VSD and encroachment on the RVOT.
370. CardioOncology: Advanced Heart Failure in CardioOncology with Dr. Richard Cheng
May 13, 2024
CardioNerds Co-Founder Dr. Daniel Ambinder, Episode Chair Dr. Dinu Balanescu, and FIT Lead Dr. Natalie Tapaskar discuss advanced heart failure in CardioOncology with expert Dr. Richard Cheng. Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig.
In this episode, we discuss the spectrum of advanced heart failure in patients with a history of cancer. We dissect cancer therapy-related cardiac dysfunction (CTRCD) cases and the imaging and biomarker tools available for risk stratification and disease monitoring. We delve into the data on the use of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy (CRT) in these patients. We discuss the risk of prior radiation and chemotherapy during cardiac surgery. Finally, we learn about the post-transplant risk of rejection, recurrent malignancy, and de-novo malignancies, as well as treatment strategies we can employ for these patients.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Advanced Heart Failure in CardioOncology
Use the HFA-ICOS risk tool to understand the baseline risk of developing cancer therapy-related cardiac dysfunction (CTRCD). Key factors are type of cancer therapy, baseline CV risk factors, and age.
A relative change in global longitudinal strain of more than 15% from baseline is a marker of early cardiac dysfunction and predicts the subsequent risk for systolic dysfunction in patients undergoing cardiotoxic chemotherapy.
Statins may be useful in prevention of cardiovascular dysfunction in patients receiving anthracycline chemotherapy. There is limited data on the 4 pillars of GDMT in prevention of CTRCD, but should be started early once CRTCD is suspected or diagnosed!
Mediastinal radiation causes adhesions and scarring which increase the risk of bleeding during cardiac surgery, lead to longer operative times, and can lead to RV failure and poor wound healing.
Patients with a pre-transplant history of malignancy have a higher risk of mortality due to post-transplant malignancy. And patients with active cancer should not be considered for heart transplant. Post-transplant malignancy risk can be mitigated by utilizing an mTOR based, CNI free immunosuppression regimen.
Show notes - Advanced Heart Failure in CardioOncology
How do cardio-oncology and advanced heart failure intersect?
There are 3 basic populations of patients to consider:Patients with advanced heart failure who develop cancer.Patients with pre-existing chemotherapy and radiation exposure for cancer treatment who later develop advanced heart failureHeart transplant recipients who, in the long term are at very high risk of developing cancer
Cardio-oncologists must consider risk assessment and mitigation, long-term prognosis, and treatment strategies for each of these unique populations.
How can we assess the risk of developing cardiovascular disease during cancer treatment (CTRCD)?
There are many proposed risk tools. However, the majority are not well-validated.
One of the most used tools is the HFA-ICOS risk tool.1You can select the planned cancer therapy for the patient (anthracyclines, HER-2, VEGF, RAF/MEK inhibitors, Kinase inhibitors, multiple myeloma therapies) and then calculate their risk of developing CV disease during cancer treatment based on baseline variables:1) previous history of CV disease,2) biomarkers – troponin and NT-proBNP3)age,4) CV risk factors -HTN, DM,
369. Case Report: Apical Obliteration with Biventricular Thrombus – West Virginia University
May 07, 2024
CardioNerds, Dr. Richard Ferraro and Dr. Dan ambinder join Dr. Li Pang, Dr. Emily Hendricks, and Dr. Bei Jiang from West Virginia University to discuss the following case that features apical obliteration with biventricular thrombus. Dr. Christopher Bianco provides the Expert CardioNerd Perspectives & Review (E-CPR) for this episode. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy.
A 37-year-old Caucasian man with a history of tobacco smoking and hypertension who presented with chest pain and elevated troponin was admitted for non-ST elevation myocardial infarction (NSTEMI). Ischemic evaluation with an invasive coronary angiogram was negative. He was treated as NSTEMI and scheduled for outpatient cardiac MRI (CMR). The patient came back 2 months later with right arm weakness and confusion and was found to have an embolic stroke. Labs showed positive troponin with a flat trend and hypereosinophilia. Transthoracic echocardiogram (TTE) showed obliteration of LV and RV apex with thrombus and reduced LV systolic function. CMR was consistent with myocarditis with biventricular thrombus. The patient was started on corticosteroids and warfarin. Hypereosinophilia workup was positive for PDGFRA alpha rearrangement. He was diagnosed with primary hypereosinophila syndrome. Imatinib was initiated. The patient was followed up with the hematology clinic, achieved a complete hematologic response with normalized cell count, and remained free from any cardiovascular event at the 8-month follow-up.
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Case Media
Pearls - Apical Obliteration with Biventricular Thrombus
Cardiac MRI is a valuable test for patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA).
Obliterated apex with apical thrombus on TTE with hypereosinophilia should raise high suspicion for eosinophilic myocarditis.
Initiation of corticosteroids is the first-line treatment for eosinophilic myocarditis, which is associated with lower mortality in patients with myocarditis. For other potential complications, such as heart failure, intracardiac thrombus, arrhythmia, and pericardial effusion, the standard of care for each disorder is recommended.
Hypereosinophilia can be seen in parasitic infections, vasculitis, asthma, allergy, hematological malignancies, and as a primary disorder.
Show Notes - Apical Obliteration with Biventricular Thrombus
What is the differential diagnosis for patients with elevated troponin and nonobstructive CAD?
The occurrence of acute myocardial infarction (AMI) without significant CAD was reported 80 years ago. However, the term MINOCA (myocardial infarction with non-obstructive coronary arteries) has only been used recently to describe these patients. It involves ischemic and nonischemic etiologies. First, overlooked ischemic etiologies need to be ruled out by reconciling the angiogram images such as spontaneous coronary artery dissection (SCAD) and plaque disruption. Intracoronary imaging, such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT), may be applied to evaluate for SCAD and subtypes of plaque disruption when indicated.
The investigation continues with nonischemic causes such as stress cardiomyopathy, myocarditis, pulmonary embolism, demand ischemia from sepsis, anemia, chest trauma, heart failure exacerbation, arrhythmia, and stroke.
The diagnosis of MINOCA is established when it fulfills the following criteria: First, it is AMI by the Fourth Universal Definition; Second, less than 50% of stenotic lesion on angiogram; Third, there is no alternate diagnosis.
368. Obesity: Procedural Management of Obesity with Dr. Steve Nissen
May 05, 2024
CardioNerds (Drs. Richard Ferraro, Gurleen Kaur, and Rupan Bose) discuss the growing epidemic of obesity and dive into the role of its procedural management with Dr. Steve Nissen, Chief Academic Officer at the Cleveland Clinic HVTI and past president of the American College of Cardiology. This is an exciting topic that reflects a major inflection point in cardiovascular care. In this episode, we discuss the importance of addressing obesity in cardiovascular care, as it is a major driver of cardiovascular disease and the progression of associated cardiovascular comorbidities. We look at the role of bariatric surgery and its ability to produce sustained weight loss. Finally, we look into the emerging role of new medical therapies such as GLP1 and GIP agonist medications. Notes were drafted by Dr. Rupan Bose and episode audio was edited by CardioNerds Intern Dr. Atefeh Ghorbanzadeh.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - Procedural Management of Obesity with Dr. Steve Nissen
Obesity is associated with adverse cardiovascular outcomes. Returning to a healthy weight can largely prevent the downstream consequences of obesity.
Regarding lifestyle modifications, diet alone is insufficient in sustaining prolonged weight loss. It is associated with short-term weight loss, but it is generally necessary to supplement with exercise and activity to ensure sustained weight loss.
Bariatric surgery should be considered for patients with BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy.
New emerging medications, including GLP1 receptor agonists, GIP receptor agonists, and glucagon receptor agonists, are beginning to approach weight loss levels that were previously only seen with bariatric surgery. Further research in this dynamic area is ongoing.
Show notes - Procedural Management of Obesity with Dr. Steve Nissen
Notes drafted by Dr. Rupan Bose.
What is the role of obesity in the burden of cardiovascular disease, and why is it so important for CardioNerds to address it?
According to the AHA, approximately 2.8 to 3.5 billion people worldwide are either overweight or obese. It is estimated that by 2030, 30% of people in the US will have a BMI greater than 30.
Adipose tissue is associated with cytokine release. Cytokines, in turn, can activate and increase levels of IL-1 beta, IL-6, and CRP, leading to an increased inflammatory state. This pro-inflammatory state then accelerates the rate of cardiovascular disease.
Obesity is also associated with significant joint and orthopedic diseases, which further impact patients’ quality of life and morbidity.
Additionally, obesity is associated with NASH cirrhosis. These adverse liver outcomes hold additional significant systemic implications and morbidity.
How do you determine one’s goal weight and goal BMI? Is BMI a good standard for measuring obesity?
BMI is a variable of both weight and height. However, it cannot differentiate those whose weight is from adipose tissue versus from muscle mass. Therefore, BMI measurements can sometimes be misleading. Waist circumference may be a better measurement standard for obesity and risk assessment.
The “apple shape” body type, with more abdominal fat, is associated with higher inflammation and cardiovascular risk than the “pear-shaped” body type, which is where there is more fat deposition in the buttocks a...
367. GLP-1 Agonists: Clinical Implementation of GLP-1 Receptor Agonists with Dr. Neha Pagidapati
May 03, 2024
CardioNerds (Drs. Gurleen Kaur and Richard Ferraro) and episode FIT Lead Dr. Spencer Carter (Cardiology Fellow at UT Southwestern) discuss the clinical implementation of GLP-1 receptor agonists with Dr. Neha Pagidapati (Faculty at Duke University School of Medicine). In this episode of the CardioNerds Cardiovascular Prevention Series, we discuss the clinical implementation of glucagon-like peptide-1 (GLP-1) receptor agonists. We cover the clinical indications, metabolic and cardiovascular benefits, and potential limitations of these emerging and exciting therapies. Show notes were drafted by Dr. Spencer Carter. Audio editing was performed by CardioNerds Academy Intern, student Dr. Pacey Wetstein.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - Clinical Implementation of GLP-1 Receptor Agonists
GLP-1 agonists work through a variety of mechanisms to counteract metabolic disease. They increase insulin secretion, inhibit glucagon secretion, slow gastric motility, and increase satiety to limit excess energy intake.
Patients with type II diabetes and an elevated risk for atherosclerotic cardiovascular disease should be considered for GLP-1 agonist therapy regardless of hemoglobin A1c.
GLP-1 agonists offer significant ASCVD risk reduction even in the absence of diabetes. Newer data suggest a significant reduction in cardiovascular events with GLP-1 agonist therapy in patients who are overweight or obese and have a prior history of heart disease.
GLP-1 agonists should generally be avoided in patients with a history of medullary thyroid cancer or MEN2. As these medications slow gastric emptying, relative contraindications include history of recurrent pancreatitis and gastroparesis.
GLP-1 agonists should be initially prescribed at the lowest dose and slowly uptitrated to avoid gastrointestinal side effects.
Show notes - Clinical Implementation of GLP-1 Receptor Agonists
What were the groundbreaking findings of the STEP1 and SURMOUNT-1 trials and how these impact cardiovascular wellness?
The STEP1 and SURMOUNT trials demonstrated sustained clinically relevant reduction in body weight with semaglutide and tripeptide, respectively, in patients with overweight and obesity. As obesity is an important risk factor for the development of cardiovascular disease, weight reduction meaningfully contributes to cardiovascular wellness.
What were the findings of the LEADER trial and their implications for patients with type II diabetes and high cardiovascular risk?
The LEADER trial demonstrated a significant reduction in the rate of cardiovascular death, nonfatal MI, or nonfatal stroke in patients with type II diabetes treated with liraglutide. GLP-1 receptor agonist therapy should be considered in all patients with type II diabetes and elevated ASCVD risk regardless of A1c or current hyperglycemic therapy.
What are current indications for GLP1 agonists in the context of cardiometabolic disease.
GLP-1 receptor agonists should be considered in patients with type II diabetes and high ASCVD risk OR patients without diabetes who are overweight/obese and have a history of cardiovascular disease.
What are important side effects or contraindications to GLP1 agents when used for cardiovascular risk reduction and wellness?
GLP-1 receptor agonists should be avoided in patients with a history of medullary thyroid cancer or MEN2. Relative contraindications include recurrent pancreatitis, gastroparesis,
366. Digital Health: Integrating Digital Health into Practice with Dr. Alexis Beatty and Dr. Seth Martin
Apr 25, 2024
CardioNerds (Dr. Dan Ambinder), Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), and Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital) join Digital Health Experts, Dr. Alexis Beatty (Cardiologist and associate professor in the department of epidemiology and biostatistics at UCSF) and Dr. Seth Martin (Director of the Johns Hopkins Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH), which is part of the American Heart Association (AHA) Strategically Focused Research Networks on Health Technology & Innovation) for another installment of the Digital Health Series. In this specific episode, we discuss pearls, pitfalls, and everything in between for emerging digital health innovators. This series is supported by an ACC Chapter Grant in collaboration with Corrie Health. Audio editing by CardioNerds Academy Intern, student doctor Shivani Reddy.
In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients.
This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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365: CardioOncology: Cardiotoxicity of Novel Immunotherapies with Dr. Tomas Neilan
Apr 22, 2024
Immunotherapy is a type of novel cancer therapy that leverages the body’s own immune system to target cancer cells. In this episode, we focused on the most common type of immunotherapy: immune checkpoint inhibitors or ICIs. ICIs are monoclonal antibodies targeting immune “checkpoints” or brakes to enhance T-cell recognition against tumors. ICI has become a pillar in cancer care, with over 100 approvals and 5,000 ongoing trials. ICIs can lead to non-specific activation of the immune system, causing off-target adverse events such as cardiotoxicities. ICI-related myocarditis, though less common, can be fatal in 30% of cases. Clinical manifestations vary but can include chest pain, dyspnea, palpitations, heart failure symptoms, and arrhythmias. Diagnosis involves echocardiography, cardiac MRI, and endomyocardial biopsy. Treatment includes high-dose corticosteroids with potential additional immunosuppressants. Baseline EKG and troponin are recommended before ICI initiation, but routine surveillance is not advised. Subclinical myocarditis is a challenge, with unclear management implications. So let’s dive in and learn about cardiotoxicity of novel immunotherapies with Drs. Giselle Suero (series co-chair), Evelyn Song (episode FIT lead), Daniel Ambinder (CardioNerds co-founder), and Tomas Neilan (faculty expert). Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Cardiotoxicity of Novel Immunotherapies
Immune checkpoint inhibitors (ICI) play a crucial role in current oncology treatment by enhancing T-cell recognition against tumors.
ICI-related cardiac immune-related adverse events (iRAEs) include myocarditis, heart failure, stress-cardiomyopathy, conduction abnormalities, venous thrombosis, pericardial disease, vasculitis, and atherosclerotic-related events.
ICI myocarditis can be fatal; thus, prompt recognition and treatment is crucial.
Management includes cessation of the ICI and treatment with corticosteroids and potentially other immunosuppressants. Close monitoring and collaboration with cardiology and oncology are crucial.
Rechallenging patients with immunotherapies after developing an iRAE is controversial and requires careful consideration of risks and benefits, typically with the involvement of a multidisciplinary team.
Show notes - Cardiotoxicity of Novel Immunotherapies
What are immune checkpoint inhibitors (ICIs)?
ICIs are monoclonal antibodies used to enhance the body’s immune response against cancer cells. Currently, there are four main classes of FDA-approved ICIs: monoclonal antibodies blocking cytotoxic T lymphocyte antigen-4 (CTLA-4), programed cell death protein-1 (PD-1), lymphocyte-activation gene 3 (LAG3), and programmed cell death ligand-1 (PD-L1).
ICIs can lead to non-specific activation of the immune system, potentially causing off-target adverse events in various organs, including the heart, leading to myocarditis.
The mechanisms of cardiac iRAEs are not fully understood, but they are believed to involve T-cell activation against cardiac antigens, which leads to inflammation and tissue damage.
What are the cardiotoxicities related to ICI therapies?
ICI-related cardiac immune-related adverse events (iRAEs) include myocarditis, heart failure, stress-cardiomyopathy, conduction abnormalities, venous thrombosis, pericardial disease, vasculitis,
364. Case Report: A Drug’s Adverse Effect Unleashes the Wolf – Beth Israel Deaconess Medical Center
Mar 14, 2024
CardioNerds join Dr. Inbar Raber and Dr. Susan Mcilvaine from the Beth Israel Deaconess Medical Center for a Fenway game. They discuss the following case: A 72-year-old man presents with two weeks of progressive dyspnea, orthopnea, nausea, vomiting, diarrhea, and right upper quadrant pain. He has a history of essential thrombocytosis, Barrett’s esophagus, basal cell skin cancer, and hypertension treated with hydralazine. He is found to have bilateral pleural effusions and a pericardial effusion. He undergoes a work-up, including pericardial cytology, which is negative, and blood tests reveal a positive ANA and positive anti-histone antibody. He is diagnosed with drug-induced lupus due to hydralazine and starts treatment with intravenous steroids, resulting in an improvement in his symptoms. Expert commentary is provided by UT Southwestern internal medicine residency program director Dr. Salahuddin (“Dino”) Kazi.
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Case Media
Pearls - A Drug's Adverse Effect Unleashes the Wolf
The differential diagnosis for pericardial effusion includes metabolic, malignant, medication-induced, traumatic, rheumatologic, and infectious etiologies.
While pericardial cytology can aid in securing a diagnosis of cancer in patients with malignant pericardial effusions, the sensitivity of the test is limited at around 50%.
Common symptoms of drug-induced lupus include fever, arthralgias, myalgias, rash, and/or serositis.
Anti-histone antibodies are typically present in drug-induced lupus, while anti-dsDNA antibodies are typically absent (unlike in systemic lupus erythematosus, SLE).
Hydralazine-induced lupus has a prevalence of 5-10%, with a higher risk for patients on higher doses or longer durations of drug exposure. Onset is usually months to years after drug initiation.
Show Notes - A Drug's Adverse Effect Unleashes the Wolf
There is a broad differential diagnosis for pericardial effusion which includes metabolic, malignant, medication-induced, traumatic, rheumatologic, and infectious etiologies. Metabolic etiologies include renal failure and thyroid disease. Certain malignancies are more likely to cause pericardial effusions, including lung cancer, lymphoma, breast cancer, sarcoma, and melanoma. Radiation therapy to treat chest malignancies can also result in a pericardial effusion. Medications can cause pericardial effusion, including immune checkpoint inhibitors, which can cause myocarditis or pericarditis, and medications associated with drug-induced lupus, such as procainamide, hydralazine, phenytoin, minoxidil, or isoniazid. Trauma can cause pericardial effusions, including blunt chest trauma, cardiac surgery, or cardiac catheterization. Rheumatologic etiologies include lupus, rheumatoid arthritis, systemic sclerosis, sarcoid, and vasculitis. Many different types of infections can cause pericardial effusions, including viruses (e.g., coxsackievirus, echovirus, adenovirus, human immunodeficiency virus, and influenza), bacteria (TB, staphylococcus, streptococcus, and pneumococcus), and fungi. Other must-not-miss etiologies include emergencies like type A aortic dissection and myocardial infarction.
In a retrospective study of all patients who presented with a hemodynamically significant pericardial effusion and underwent pericardiocentesis, 33% of patients were found to have an underlying malignancy(Ben-Horin et al). Bloody effusion and frank tamponade were significantly more common among patients with malignant effusion, but the overlap was significant, and no epidemiologic or clinical parameter was found useful to differentiate between cancerous and noncancerous effus...
363. GLP-1 Agonists: Diving into the Data with Dr. Darren McGuire
Mar 12, 2024
Welcome back to the CardioNerds Cardiovascular Prevention Series, where we are continuing our discussion of Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs). This class of medications is becoming a household name, not only for their implications for weight loss but also for their effect on cardiovascular disease. CardioNerds Dr. Ty Sweeney (CardioNerds Academy Faculty Member and incoming Cardiology Fellow at Boston Medical Center), Dr. Rick Ferraro (CardioNerds Academy House Faculty and Cardiology Fellow at Johns Hopkins Hospital), and special guest Dr. Franck Azobou (Cardiology Fellow at UT Southwestern) sat down with Dr. Darren McGuire (Cardiologist at UT Southwestern and Senior Editor of Diabetes and Vascular Disease Research) to discuss important trial data on GLP-1 RAs in patients with heart disease, as well as recent professional society guidelines on their use. Show notes were drafted by Dr. Ty Sweeney. Audio editing was performed by CardioNerds Intern student Dr. Diane Masket.
If you haven’t already, be sure to check out CardioNerds episode #350 where we discuss the basics and mechanism of action of GLP-1 RAs with Dr. Dennis Bruemmer.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - GLP-1 Agonists: Diving into the Data
Patients with diabetes and clinical atherosclerotic cardiovascular disease (ASCVD) or who are at high risk of ASCVD benefit from treatment with a GLP-1 RA.
For persons with sufficient ASCVD risk and type 2 diabetes, GLP-1 RAs and SGLT2 inhibitors can, and often should, be used in combination. "Just like we don’t consider ‘and/or’ for the four pillars of guideline-directed medical therapy for heart failure with reduced ejection fraction, we shouldn’t parcel out these two therapeutic options...it should be both.”
Setting expectations with your patients regarding injection practices, side effects, and expected benefits can go a long way toward improving the patient experience with GLP-1 RAs.
Utilize a multidisciplinary approach when caring for patients on GLP-1 RAs. Build a team with your patient’s primary care provider, endocrinologist, clinical pharmacist, and nurse.
“This is really a cardiologist issue. These are no longer endocrinology or primary care drugs. We need to be prescribing them ourselves just like we did back in the nineties when we took over the statin prescriptions from the endocrinology domain...we need to lead the way.”
Show notes - GLP-1 Agonists: Diving into the Data
For which patients are GLP-1 RAs recommended to reduce the risk of major cardiac events?
For patients with type 2 diabetes and ASCVD, starting a GLP-1 RA carries a Class 1, Level of Evidence A recommendation in the most recent ESC and ACC guidelines.
For patients without diabetes or clinical ASCVD with an estimated 10-year risk of CVD exceeding 10%, consideration of starting a GLP-1 RA carries a Class 2b, Level of Evidence C recommendation to reduce CV risk.
The STEP-HFpEF trial showed that among patients with obesity and HFpEF, once-weekly semaglutide may be beneficial in terms of weight loss and quality of life.
The results of the FIGHT and LIVE trials question the utility and safety of liraglutide in treating patients with advanced HFrEF. Of the over 17,000 patients enrolled in the SELECT trial, about 25% had heart failure, of which about one-third had HFrEF. Stay tuned for sub-analyses from that trial for more info!
Can we still prescribe GLP-1 Ras in patients with well-controlled T2DM?
362. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #32 with Dr. Harriette Van Spall
Mar 10, 2024
The following question refers to Section 13 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy Faculty Dr. Dinu Balanescu, and then by expert faculty Dr. Harriette Van Spall.Dr. Van Spall is an Associate Professor of Medicine, cardiologist, and Director of E-Health at McMaster University. Dr Van Spall is a Canadian Institutes of Health Research-funded clinical trialist and researcher with a focus on heart failure, health services, and health disparities.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #32
Palliative and supportive care has a role for patients with heart failure only in the end stages of their disease.
TRUE
FALSE
Answer #32
Explanation
The correct answer is False
Palliative care is patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering and should be integrated into the management of all stages of heart failure throughout the course of illness. The wholistic model of palliative care includes high-quality communication, estimation of prognosis, anticipatory guidance, addressing uncertainty, shared decision-making about medically reasonable treatment options, advance care planning; attention to physical, emotional, spiritual, and psychological distress; relief of suffering; and inclusion of family caregivers in patient care and attention to their needs during bereavement.
As such, for all patients with HF, palliative and supportive care—including high-quality communication, conveyance of prognosis, clarifying goals of care, shared decision-making, symptom management, and caregiver support—should be provided to improve QOL and relieve suffering (Class 1, LOE C-LD).
For conveyance of prognosis, objective risk models can be incorporated along with discussion of uncertainty since patients may overestimate survival and the benefits of specific treatments – “hope for the best, plan for the worst.”
For clarifying goals of care, the exploration of each patient’s values and concerns through shared decision-making is essential in important management decisions such as when to discontinue treatments, when to initiate palliative treatments that may hasten death but provide symptom management, planning the location of death, and the incorporation of home services or hospice.
It is a Class I indication that for patients with HF being considered for, or treated with life-extending therapies, the option for discontinuation should be anticipated and discussed through the continuum of care, including at the time of initiation, and reassessed with changing medical conditions and shifting goals of care (LOE C-LD).
Caregiver support should also be offered to family members even beyond death to help them cope with the grieving process.
A formal palliative care consult is not needed for each patient, but the primary team should exercise the above domains to improve processes of care and patient outcomes.
Specialist palliative care consultation can be useful to improve QOL and relieve suffering for patients with heart failure—particularly tho...
361. Case Report: Sore Throat, Fever, and Myocarditis – It’s not always COVID-19! – University of Maryland
Mar 05, 2024
CardioNerds cofounder Dr. Dan Ambinder joins Dr. Angie Molina, Dr. Cullen Soares, and Dr. Andrew Lutz from the University of Maryland Medical Center for some beers and history by Fort McHenry. They discuss a case of disseminated haemophilus influenzapresumed fulminant bacterial myocarditis with mixed septic/cardiogenic shock. Expert commentary is provided by Dr. Stanley Liu (Assistant Professor, Division of Cardiovascular Medicine, University of Maryland School of Medicine). Episode audio was edited by Dr. Chelsea Amo-Tweneboah.
A woman in her twenties with a history of intravenous drug use presented with acute onset fevers and sore throat, subsequently developed respiratory distress and cardiac arrest, and was noted to have epiglottic edema on intubation. She developed shock and multiorgan failure. ECG showed diffuse ST elevations, TTE revealed biventricular dysfunction, and pleural fluid culture grew Haemophilus influenza. Right heart catheterization showed evidence of cardiogenic shock. She improved with supportive care and antibiotics.
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Pearls - Sore Throat, Fever, and Myocarditis - It’s not always COVID-19
The post-cardiac arrest ECG provides helpful information for diagnosing the underlying etiology.
Be aware of diagnostic biases - availability and anchoring biases are particularly common during respiratory viral (such as COVID-19, RSV) surges.
Consider a broad differential diagnosis in evaluating myocarditis, including non-viral etiologies.
Right heart catheterization provides crucial information for diagnosis and management of undifferentiated shock.
When assessing the need for mechanical circulatory support, consider the current hemodynamics, type of support needed, and risks associated with each type.
Show Notes - Sore Throat, Fever, and Myocarditis - It’s not always COVID-19
ECG findings consistent with pericarditis include diffuse concave-up ST elevations and downsloping T-P segment (Spodick’s sign) as well as PR depression (lead II), and PR elevation (lead aVR). In contrast, regional ST elevations with “reciprocal” ST depressions and/or Q-waves should raise concern for myocardial ischemia as the etiology.
Biventricular dysfunction and elevated troponin are commonly seen post-cardiac arrest and may be secondary findings. However, an elevation in troponin that is out of proportion to expected demand ischemia, ECG changes (pericarditis, ischemic ST elevations), and cardiogenic shock suggest a primary cardiac etiology for cardiac arrest.
The differential diagnosis of infectious myopericarditis includes, most commonly, viral infection (respiratory viruses) and, more rarely, bacterial, fungal, or parasitic. Noninfectious myopericarditis may be autoimmune (such as lupus, sarcoidosis, checkpoint inhibitors), toxin-induced (alcohol, cocaine), and medication-induced (anthracyclines and others).
Right heart catheterization can help diagnose the etiology of undifferentiated shock, including distinguishing between septic and cardiogenic shock, by providing right and left-sided filling pressures, pulmonary and systemic vascular resistance, and cardiac output.
Mechanical circulatory support (MCS) is indicated for patients in cardiogenic shock with worsening end-organ perfusion despite inotropic and pressor support. MCS includes intra-aortic balloon pump, percutaneous VAD, TandemHeart, and VA-ECMO. The decision to use specific types of MCS should be individualized to each patient with their comorbidities and hemodynamic profile. Shock teams are vital to guide decision-making.
References
Witting MD, Hu KM, Westreich AA, Tewelde S, Farzad A,
360. Obesity: Lifestyle & Pharmacologic Management of Obesity with Dr. Ambarish Pandey
Feb 19, 2024
CardioNerds Dr. Rick Ferraro (CardioNerds Academy House Faculty and Cardiology Fellow at JHH), Dr. Gurleen Kaur (Director of the CardioNerds Internship and Internal Medicine resident at BWH), and Dr. Alli Bigeh (Cardiology Fellow at the Ohio State) as they discuss the growing obesity epidemic and how it relates to cardiovascular disease with Dr. Ambarish Pandey (Cardiologist at UT Southwestern Medical Center). Show notes were drafted by Dr. Alli Bigeh. CardioNerds Academy Intern and student Dr. Shivani Reddy performed audio editing.
Obesity is an important modifiable risk factor for cardiovascular disease, and it is on the rise! Here, we discuss how to identify patients with obesity and develop an approach to address current lifestyle recommendations. We also discuss the spectrum of pharmacologic treatment options available, management strategies, and some therapy options that are on the horizon.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - Lifestyle & Pharmacologic Management of Obesity
Identify obese patients not just using BMI, but also using anthropometric measurements such as waist circumference (central adiposity).
Lifestyle modifications are our first line of defense against obesity! Current recommendations emphasize caloric restriction of at least 500kcal/day, plant-based and Mediterranean diets, and getting at least 150 minutes of moderate-intensity weekly exercise.
Dive into the root cause of eating and lifestyle behaviors. It is crucial to address adverse social determinants of health with patients to identify the driving behaviors, particularly among those individuals of low socioeconomic status.
Newer weight loss agents are most effective at achieving and maintaining substantial weight loss, in particular Semaglutide (GLP-1) and Tirzepatide (GLP-1/GIP). Initiate at a low dose and titrate up slowly.
Obesity is a risk factor and potential driver for HFpEF. Targeted treatment options for obese patients with HFpEF include SGLT-2 inhibitors and semaglutide, which recently showed improvement in quality of life and exercise capacity in the STEP-HFpEF trial.
Show notes - Lifestyle & Pharmacologic Management of Obesity
How do we identify and define obesity?
The traditional definition of obesity is based on body mass index (BMI), defined as BMI greater than or equal to 30.0 kg/m2 (weight in kg/height in meters).Recognize that BMI may not tell the whole story. A limitation of BMI is it does not reflect differences in body composition and distribution of fat.Certain patients may not meet the BMI cutoff for obesity but have elevated cardiovascular risk based on increased central adiposity, specifically those that are categorized as overweight.The devil lies in the details of anthropometric parameters. Include waist circumference measurements as part of an obesity assessment of visceral adiposity.
A waist circumference greater than 40 inches for men and greater than 35 inches for women is considered elevated.
What are some current lifestyle recommendations for obese patients?
Lifestyle recommendations are the first line of defense against obesity.Current ACC/AHA guidelines suggest a target of reducing caloric intake by 500 kcal per day. For patients with severe obesity, this number may be higher.Emphasis on hypocaloric plant-based and Mediterranean dietsReduce total carbohydrate intake to 50-130 grams per day.Focus on a low-fat diet with less than 30% of total energy coming from fat with a high-protein diet to main...
359. Case Report: Fee-Fi-Fo-Fum: An Unusual Case of Rapidly Progressive Heart Failure – Georgetown University
Feb 12, 2024
CardioNerds join Dr. Ethan Fraser and Dr. Austin Culver from the MedStar Georgetown University Hospital internal medicine and cardiology programs in our nation’s capital. They discuss the following case involving an unusual case of rapidly progressive heart failure. Episode audio was edited by CardioNerds Academy Intern and student Dr. Pacey Wetstein. Expert commentary was provided by advanced heart failure cardiologist Dr. Richa Gupta.
A 55-year-old male comes to the clinic (and eventually into the hospital) for what appears to be a straightforward decompensation of his underlying cardiac disease. However, things aren’t as simple as they might appear. In this episode, we will discuss the outpatient workup for non-ischemic cardiomyopathy and discuss the clinical indicators that we as clinicians should be aware of in these sick patients. Furthermore, we will discuss the differential for NICM, the management of patients with this rare disease, and how this disease can mimic other cardiomyopathies.
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Case Media - Rapidly Progressive Heart Failure
Pearls - Rapidly Progressive Heart Failure
The non-ischemic cardiomyopathy workup should incorporate targeted multimodal imaging, thorough history taking, broad laboratory testing, genetic testing if suspicion exists for a hereditary cause, and a deep understanding of which populations are at higher risk for certain disease states.
Key Point: Always challenge and question the etiology of an unknown cardiomyopathy – do not assume an etiology based on history/patient story alone.
Unexplained conduction disease in either a young or middle-aged individual in the setting of a known cardiomyopathy should raise suspicion for an infiltrative cardiomyopathy and set off a referral to an advanced heart failure program.
Key Point: Consider early/more aggressive imaging for these patients and early electrophysiology referral for primary/secondary prevention.
Giant Cell Myocarditis is a rapidly progressive cardiomyopathy characterized by high mortality (70% in the first year), conduction disease, and classically presents in young/middle-aged men.
Key Point: If you have a younger male with rapidly progressive cardiomyopathy (anywhere as quickly as 1-2 months, weeks in some cases) and conduction disease, consider early endomyocardial biopsy, even before other advanced imaging modalities.
The Diagnosis of Giant Cell Myocarditis is time-sensitive - early identification and treatment are essential to survival.
Key Point: The median timeframe from the time the disease is diagnosed to the time of death is approximately 6 months. 90% of patients are either deceased by the end of 1 year or have received a heart transplant.
The treatment of Giant Cell Myocarditis is still governed largely by expert opinion, but the key components include high-dose steroids and cyclosporine, largely as a bridge to transplantation or advanced heart failure therapies.
Key Point: Multi-disciplinary care is essential in delivering excellent care in the diagnostic/pre-transplant period, including involvement by cardiology, cardiac surgery, radiology, critical care, allergy/immunology, case management, advanced heart failure, and shock teams if necessary.
There remains significant clinical overlap between Giant Cell Myocarditis and sarcoidosis, making managing equivocal cases challenging.
Key Point: Consider early FDG-PET imaging in equivocal cases, as management during the pre-transplant period and evaluation of transplant candidacy can vary drastically between the two.
Show Notes - Rapidly Progressive Heart Failure
1.
358. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #31 with Dr. Javed Butler
Feb 09, 2024
The following question refers to Section 9.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & former CardioNerds Intern Hirsh Elhence, answered first by Vanderbilt Cardiology Fellow and CardioNerds Academy Faculty Dr. Breana Hansen, and then by expert faculty Dr. Javed Butler.
Dr. Butler is an advanced heart failure and transplant cardiologist, President of the Baylor Scott and White Research Institute, Senior Vice President for the Baylor Scott and White Health, and Distinguished Professor of Medicine at the University of Mississippi
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #31
Mrs. Hart is a 70-year-old woman who was admitted to the CICU two days ago for signs and symptoms consistent with cardiogenic shock. Since her admission, she has been on maximal diuretics, requiring greater doses of intravenous dobutamine. Unfortunately, her liver and renal function continue to worsen, and urine output is decreasing. A right heart catheterization reveals elevated biventricular filling pressures with a cardiac index of 1.7 L/min/m2 by the Fick method.
What is the next best step?
A
Continue current measures and monitor for improvement
B
Switch from dobutamine to norepinephrine
C
Place an intra-aortic balloon pump (IABP)
D
Resume guideline directed medical therapy
Answer #31
Explanation
The Correct answer is C – Place an intra-aortic balloon pump.
This patient is between the SCAI Shock Stages C and D with elevated venous pressures, decreased urine output, and worsening signs of hypoperfusion. She has been started on appropriate therapies, including diuresis and inotropic support. The relevant Class 2a recommendation is that in patients with cardiogenic shock, temporary MCS is reasonable when end-organ function cannot be maintained by pharmacologic means to support cardiac function (LOE B-NR). Thus, the next best step is a form of temporary MCS. IABP is appropriate to help increase coronary perfusion and offload the left ventricle. In fact, for patients who are not rapidly responding to initial shock measures, triage to centers that can provide temporary MCS may be considered to optimize management (Class 2b, LOE C-LD).
The guidelines further state that in patients presenting with cardiogenic shock, placement of a pulmonary arterial line may be considered to define hemodynamic subsets and appropriate management strategies (Class 2B, LOE B-NR). And so, if time allows escalation to MCS should be guided by invasively obtained hemodynamic data via PA catheterization. Several observational experiences have associated PA catheterization use with improved outcomes, particularly in conjunction with short-term MCS. Additionally, PA catheterization is useful when there is diagnostic uncertainty as to the cause of hypotension or end-organ dysfunction, particularly when the patient in shock is not responding to empiric initial measures, such as in this patient.
There are additional appropriate measures at this time that are more institution-dependent. An institutional shock team would be very helpful here as they often comprise multidisciplinary teams of heart failure and critical care specialists,
357. CardioOncology: Cardiac Tumors with Dr. Juan Lopez-Mattei
Feb 08, 2024
CardioNerds co-founder Dr. Dan Ambinder, series chair Dr. Teodora Donisan, and Dr. Sukriti Banthiya discuss cardiac tumors with Dr. Juan Lopez-Mattei, a nationally recognized expert in the fields of cardio-oncology and the director of cardiac imaging at the Lee Health Heart Institute. Here, we explore the topic of cardiac tumors, with a focus on distinguishing between primary and secondary tumors. We delve into the symptoms, diagnostic methods, and treatment options. Show notes were drafted by Dr. Sukriti Banthiya and episode audio was edited by CardioNerds Intern and student Dr. Diane Masket.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Cardiac Tumors
Keep it simple when approaching an intracardiac mass; start with transthoracic echocardiography (TTE) and use transesophageal echocardiography (TEE) or cardiac magnetic resonance (CMR) based on the clinical context. Use TEE when suspecting valvular vegetations or thrombi & CMR for intracavitary cardiac masses.
Cardiac tumors can manifest with a variety of symptoms; however, they are more commonly diagnosed as an incidental finding!
When faced with the dilemma of selecting the most suitable imaging modality for evaluating a cardiac mass, consider the following hierarchy: begin with TTE as the first choice, followed by CMR. If the patient cannot undergo CMR, the next step is cardiac computed tomography (CT) or Fluorodeoxyglucose F18 positron emission tomography (FDG-PET).
TEE is especially useful for the evaluation of small, highly mobile cardiac masses!
Imaging cannot substitute a tissue diagnosis of cardiac masses. However, in cases of advanced malignancy, it may not always be necessary.
Show notes - Cardiac Tumors
Segment One: A big “picture” Approach to Cardiac Tumors
Let’s start with an overview of cardiac masses
Neoplastic vs non-neoplasticNeoplastic lesions can be further classified into Primary Cardiac Tumors (PCT’s) & Secondary Cardiac Tumor (SCT’s)A majority of PCTs are benign (up to 90%!); however, rarely, they may be malignant.
SCTs are more common than PCTs, and, by definition, they are malignant tumors.
Now, let’s look at the tools you can use to aid with the diagnosis of cardiac masses…
Step 1: Investigate the cardiac mass initially with TTE.
Step 2: Collect clues through history-taking & examination.If suspecting valvular vegetations (as in infective endocarditis!) or left atrial appendage thrombus, characterize the mass further with TEE.Consider the possibility of metastatic cardiac tumors in patients with a known malignancy, as they are more common than primary cardiac tumors.
In cases where it is uncertain if the mass is a cardiac tumor or thrombus, use CMR to differentiate the two entities.
Some findings on TTE that support the presence of a thrombus include left ventricular dysfunction with segmental wall motion abnormalities and/or apical aneurysm as these result in local pockets of stasis (think: Virchow’s triad)
Step 3: Put it all together!
Think about whether a tissue biopsy will be needed. If yes, determine whether a negative margin or open biopsy will be required.
Segment Two: Symptoms, Symptoms, Symptoms!
Cardiac tumors may be symptomatic and present in the 3 key ways as outlined below (Think COD 🐟). However, they are more commonly identified as incidental findings!
Constitutional symptoms (fever, arthralgias, weight loss,
356. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guidelines – Key Takeaways with Dr. José Joglar and Dr. Mina Chung
Jan 23, 2024
CardioNerds Atrial Fibrillation Series Co-Chairs Dr. Colin Blumenthal (University of Pennsylvania Cardiology fellow) and Dr. Kelly Arps (Duke University Electrophysiology Fellow) join the 2023 atrial fibrillation guideline writing committee Chair Dr. José Joglar (UT Southwestern) and Vice Chair Dr. Mina Chung (Cleveland Clinic). They review the key takeaways from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Audio editing by CardioNerds academy intern, student doctor Pace Wetstein.
This podcast was developed in collaboration with the American Heart Association. For more on these guidelines, access the AHA Science News AF Guideline landing page.
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355. Case Report: Hypertension With a Twist – Mount Sinai Medical Center
Jan 16, 2024
CardioNerds nerd out with Drs. Karishma Rahman (Mount Siani Vascular Medicine fellow), Shu Min Lao (Mount Sinai Rheumatology fellow), and Constantine Troupes (Mount Sinai Vascular Surgery fellow). They discuss the following case: A 20-year-old woman with a history of hypertension (HTN), initially thought to be secondary to a mid-aortic syndrome that resolved after aortic stenting, presents with a re-occurrence of HTN. The case will go through the differential diagnosis of early onset HTN focusing on structural etiologies of HTN, including mid-aortic syndrome and aortitis. We will also discuss the multi-modality imaging used for diagnosis and surveillance, indications and types of procedural intervention, and how to diagnose and treat an underlying inflammatory disorder leading to aortitis. The expert commentary was provided by Dr. Daniella Kadian-Dodov, Associate Professor of Medicine and Vascular Medicine specialist at the Icahn School of Medicine at Mount Sinai. Audo editing was performed by Dr. Chelsea Amo-Tweneboah, CardioNerds Academy Intern and medicine resident at Stony Brook University Hospital.
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Case Media - Hypertension With a Twist
Pearls - Hypertension With a Twist
Early onset hypertension (HTN) and lower extremity claudication should raise suspicion for aortic stenosis (including mid-aortic syndrome). Initial evaluation should include arterial duplex ultrasound and cross-sectional imaging such as CT or MR angiogram of the chest, abdomen, and pelvis to assess for arterial stenosis involving the aorta and/or branching vessels.
Mid-aortic syndrome can have multiple underlying etiologies. Concentric aortic wall thickening should raise suspicion for an underlying inflammatory disorder. Initial evaluation should include inflammatory markers such as ESR, CRP, and IL-6, but normal values do not exclude underlying aortitis.
While Takayasu arteritis is the most common inflammatory disorder associated with mid-aortic syndrome, IgG4-RD should also be a part of the differential diagnosis. IgG subclass panel can detect IgG4-RD with elevated serum IgG4 levels, but some cases can require pathology for diagnosis.
Catheter based intervention is a safe and effective treatment of aortic stenosis for both primary aortic stenosis and post-procedural re-stenosis.
Multi-modality imaging, including cross-sectional imaging and duplex ultrasound, plays a central role for the diagnosis, management, and post-procedural surveillance of aortic disease.
A multi-disciplinary team (as exemplified by the participants of this podcast!) is essential for the management of complex aortopathy cases to optimize clinical outcomes.
Show Notes - Hypertension With a Twist
1. Early onset HTN can have multiple etiologies – aortic stenosis (including but not limited to secondary to congenital aortic coarctation and mid–aortic syndrome, as well as in stent re-stenosis if there is a history of aortic stenting), thrombosis, infection, inflammatory/autoimmune disorders, renovascular disease, polycystic kidney disease, and endocrine disorders.
2. Mid-aortic syndrome is characterized by segmental or diffuse narrowing of the abdominal and/or distal descending aorta with involvement of the branches of the proximal abdominal aorta (renal artery, celiac artery, superior mesenteric artery) and represents approximately 0.5 to 2% of all cases of aortic narrowing. Underlying etiologies include genetic syndromes, inflammatory, non-inflammatory, and idiopathic. It is important to have a high suspicion of underlying inflammatory disorders if cross-sectional i...
354. Obesity: Obesity & Cardiovascular Disease Risk with Dr. Jaime Almandoz
Jan 09, 2024
CardioNerds Dr. Rick Ferraro (cardiology fellow at Johns Hopkins Hospital) and Dr. Eunice Dugan (cardiology fellow at the Cleveland Clinic) join episode lead Dr. Tiffany Brazile (cardiology fellow at the University of Texas Southwestern Medical Center and postdoctoral fellow at the Institute for Exercise and Environmental Medicine) to discuss the impact of obesity on cardiovascular disease risk, differential risk in specific populations, and effective strategies for counseling patients. They are joined by expert Dr. Jaime Almandoz, Medical Director of the Weight Wellness Program and an Associate Professor of Medicine at the University of Texas Southwestern Medical Center. Audio editing was performed by CardioNerds Academy Intern, student Dr. Tina Reddy.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - Obesity & Cardiovascular Disease Risk
The durability of metabolically healthy obesity (i.e., normal A1c, lipids, LFTs, BMP, normotensive) is limited. Within 5 years, a third of adults with “metabolically healthy” obesity will develop a cardiometabolic complication.
The biomechanical and psychosocial complications of obesity are just as important as the cardiometabolic complications. Biomechanical and psychosocial complications, including obstructive sleep apnea, joint pain, and mood disorders also influence cardiovascular disease risk.
Weight loss is not always the patient’s goal. Meet patients where they are and understand their challenges, concerns, and long-term goals with respect to their cardiovascular health and obesity. This information provides an opportunity to frame the conversation in a supportive and engaging way that allows for patient education.
Body mass index (BMI) is a screening tool for obesity, but is not sufficient for providing individualized care.
Obesity management methods that result in rapid weight loss may not be appropriate for all patients. These methods, such as bariatric surgery and GLP1-receptor agonists, require regular monitoring, follow-up, and multidisciplinary care (e.g., nutritionist, exercise physiologist, endocrinologist, cardiologist, psychologist, etc.).
Show notes - Obesity & Cardiovascular Disease Risk
Is it possible to be healthy at any size?
Whether an individual can be healthy at any size depends on the definition of health and its durability.Approximately 10-15% of adults with obesity are metabolically healthy.The risk for developing cardiometabolic disease is higher in obese versus non-obese adults. One in three adults with metabolically healthy obesity will develop cardiometabolic complications (i.e., insulin resistance/diabetes, hyperlipidemia, hypertension) within five years. Thus, metabolically healthy obesity may represent a transient phenotype with adverse long-term consequences.
Consider non-metabolic health consequences of obesity that also influence cardiovascular disease risk.
Obstructive sleep apnea, joint pain leading to decreased physical activity, and mood disorders are key considerations here and encompass the biomechanical and psychosocial consequences of obesity.
Does large, rapid weight loss result in poorer long-term weight loss than slower, gradual weight loss?
When approaches to weight loss are not sustainable, such as extremely low-calorie diets or extreme fitness regimens, the results and associated health benefits are less likely to be durable.
Rapid, large-magnitude weight loss is appropriate for some adults with obesity and can be achieved throug...
353. Atrial Fibrillation: Anticoagulation Pharmacology & Clinical Decision-Making with Dr. Ashley Lochman and Dr. Chris Domenico
Dec 29, 2023
CardioNerds co-founder Dr. Amit Goyal, series co-chair Dr. Colin Blumenthal, and episode lead Dr. Anushka Tandon to discuss pharmacologic anticoagulation options in atrial fibrillation with Drs. Ashley Lochman and Chris Domenico. The case-based review helps clarify some key concepts, such as when warfarin is preferred for anticoagulation, who may be a good DOAC (direct-acting oral anticoagulant) candidate, how to choose an appropriate DOAC agent, and how to manage anticoagulation therapy in patients already on antiplatelet therapies. Notes were drafted by Dr. Anushka Tandon. The episode audio was edited by student Dr. Shivani Reddy.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This episode was planned and recorded prior to the release of the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Please refer to this guideline document for the most updated recommendations.
We have collaborated with VCU Health to provide CME. Claim free CME here!
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Pearls and Quotes - Anticoagulation Pharmacology
Avoid potentially fatal errors with this terminology tip for correctly referencing non-warfarin oral anticoagulant agents: it’s DOAC (like, please DO use AntiCoagulation), not NOAC (imagine someone interpreting that as “NO AntiCoagulation for this patient” at discharge – yikes)!
Sometimes, an oldie really is a goodie – warfarin is recommended over DOACs for patients with mechanical heart valves, moderate-to-severe mitral stenosis, anti-phospholipid antibody syndrome (APLS), left ventricular (LV) thrombus, higher INR goals, or DOAC failure. Patient preference and medication costs should also be considered – at the end of the day, “the best drug is the drug that a patient is willing to take!”
Standard-dose rivaroxaban or apixaban may be considered for use in patients weighing >120kg or with BMI >40; use of other DOACs should be limited to pts weighing =/< 120kg or with BMI =/< 40.
The pharmacists involved in this podcast promise they don’t have stock in apixaban! It just often happens to be the preferred DOAC option in certain scenarios – think patients with severe renal impairment (including ESRD) or with an increased risk for bleeding events (including older adults, those with a history of GI bleed, etc).
In general, dual therapy (DOAC or warfarin + P2Y12 inhibitor) is non-inferior to triple therapy (oral anticoagulant + P2Y12 inhibitor + aspirin) at preventing thrombotic events but is associated with a lower risk of bleeding events. Most patients can be transitioned to dual therapy after 7-30 days on triple therapy post-percutaneous coronary intervention.
What’s that on the horizon? Factor XI inhibitors may become the breakout stars of anticoagulation – multiple investigational agents are being studied for their potential to reduce thrombotic risk without significantly increasing bleeding risk in patients with indications for anticoagulation therapy…at least that’s the theorize hope. Watch this space!
Notes - Anticoagulation Pharmacology
In which cases is warfarin preferred over DOACs in patients with atrial fibrillation?
Long-term anticoagulation with warfarin is indicated in patients with atrial fibrillation and either a mechanical valve or moderate-to-severe mitral stenosis (i.e., valvular atrial fibrillation as defined in the 2019 AHA/ACC/HRS guidelines on atrial fibrillation [1]). The REALIGN trial [2] showed increased rates of thromboembolic and bleeding complications with dabigatran vs.
352. Case Report: The Culprit in the Pillbox – University of Kansas
Dec 27, 2023
CardioNerds (Dr. Amit Goyal) join Dr. Anureet Malhotra, Dr. John Fritzlen, and Dr. Tarun Dalia from the University of Kansas School of Medicine for some of Kansas City’s famous barbeque. They discuss a case of Hydroxychloroquine induced cardiomyopathy. Notes were drafted by Dr. Anureet Malhotra, Dr. John Fritzlen, and Dr. Tarun Dalia. Expert commentary was provided by Dr. Pradeep Mammen. The episode audio was edited by Dr. Akiva Rosenzveig.
Drug-induced cardiomyopathy remains an important and under-recognized etiology of cardiomyopathy and heart failure. Hydroxychloroquine is a disease-modifying antirheumatic drug used for various rheumatological conditions, and its long-term use is well-known to have toxic effects on cardiac muscle cells. Multiple cardiac manifestations of these drugs have been identified, the most prominent being electrophysiological disturbances.
In this episode, we discuss a biopsy-proven case of hydroxychloroquine-induced cardiotoxicity with detailed histopathological and imaging findings. We develop a roadmap for the diagnosis of hydroxychloroquine-induced cardiomyopathy and discuss the various differentials of drug-induced cardiomyopathy. We highlight the importance of clinical monitoring and early consideration of drug-induced toxicities as a culprit for heart failure.
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Case Media - Hydroxychloroquine induced cardiomyopathy
Pearls - Hydroxychloroquine induced cardiomyopathy
Continued decline in left ventricular systolic function despite appropriate guideline directed medical therapy should prompt a thorough evaluation for unrecognized etiologies and warrants an early referral to advanced heart failure specialists.
Transthoracic echocardiogram is a valuable non-invasive screening tool for suspected pulmonary hypertension, but right heart catheterization is required for definitive diagnosis.
Cardiac MRI can be used for better characterization of myocardial tissue and can aid in the evaluation of patients with non-ischemic cardiomyopathy.
Hydroxychloroquine (HCQ) is a commonly used DMARD that remains an underrecognized etiology of cardiomyopathy and heart failure. In addition to ophthalmological screening, annual ECG, as well as echocardiography screening for patients on long-term HCQ therapy, should be considered in patients at risk for cardiovascular toxicity, including those with pre-existing cardiovascular disease, older age, female sex, longer duration of therapy, and renal impairment.
Management of hydroxychloroquine-associated cardiomyopathy consists of discontinuing hydroxychloroquine and standard guideline-directed medical therapy for heart failure. HCQ cardiomyopathy may persist despite medical therapy, and advanced therapy options may have to be considered in those with refractory heart failure.
Show Notes - Hydroxychloroquine induced cardiomyopathy
What are the various cardiotoxic effects of hydroxychloroquine (HCQ) and the mechanism of HCQ-mediated cardiomyopathy?
One of the most frequently prescribed disease-modifying antirheumatic drugs (DMARDs), HCQ is an immunomodulatory and anti-inflammatory agent that remains an integral part of treatment for a myriad of rheumatological conditions. Its efficacy is linked to inhibiting lysosomal antigen processing, MHC-II antigen presentation, and TLR functions.8 The known cardiac manifestations of HCQ-induced toxicity include conduction abnormalities, ventricular hypertrophy, hypokinesia, and lastly, cardiomyopathy.
Conduction Abnormalities - by binding to and inhibiting the human ether-à-go-go-related gene (hERG) voltage-gated potassium channel,
351. Case Report: The Tall Tail Heart: Angioleiomyoma – The Christ Hospital
Dec 20, 2023
CardioNerds meet with fellows from The Christ Hospital, Drs. Hanad Bashir, Hyunsoo Chung, and Dalia Aziz to discuss the following case that highlights angioleiomyoma:
A 60-year-old woman with a past medical history significant for breast cancer (on tamoxifen) presented as a transfer to our facility for a clot-in-transit. She had initially presented to the outside hospital after progressive dyspnea on exertion and recent syncope. She was found on an echocardiogram to have a right atrial mass spanning into the right ventricle. CTA of the chest and abdomen/pelvis demonstrated extensive thrombus burden spanning from the IVC into the right ventricle. She was transferred to our facility for intervention.
Endovascular attempts were unsuccessful, at which point she underwent surgical thrombectomy. Gross examination of the mass revealed a cylindrical shape, homogeneous tan color, rubbery soft tissue, measuring 25.5 cm in length and 2.3 cm in diameter. Histology confirmed the presence of angioleiomyoma. A second, smaller mass (5.2cm long and 4mm in diameter) was removed from under the tricuspid valve, with histology consistent with leiomyoma. Estrogen receptor and progesterone receptor staining were strongly positive, leading to the discontinuation of tamoxifen. Given the presence of uterine fibroids identified on the CT scan, there was concern about a uterine origin. A hysterectomy is planned for her in the near future.
Expert commentary is provided by Dr. Wojciech Mazur. Episode audio was edited by student Dr. Adriana Mares.
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Case Media - The Tall Tail Heart: Angioleiomyoma – The Christ Hospital
Pearls - The Tall Tail Heart: Angioleiomyoma – The Christ Hospital
Although evaluation of cardiac mass by echocardiography can provide information such as size, location, and morphology, adjunctive cross-sectional imaging may be used depending on the need for further temporal resolution (CT) or tissue characterization via cardiac MRI (CMR). If suspicious for elevated metabolic activity, there should be consideration of FDG-PET.
Tamoxifen (a selective estrogen receptor modulator) is an agent used for breast cancer therapy. However, its use has been associated with endometrial hyperplasia, uterine fibroids, endometrial and uterine malignancy. Increased risk of malignancy has been seen more often in post-menopausal women and is dose and time-dependent.
Clot in transient is a mobile thrombus, typically within the right heart structures. It is estimated to occur in 4-18% of patients with pulmonary embolism and is associated with elevated morbidity and mortality. Treatment includes surgical embolectomy, endovascular embolectomy, systemic thrombolysis, catheter-directed thrombolysis, or systemic anticoagulation.
Angioleiomyoma is a rare benign pericystic tumor that most commonly affects the extremities. There are case reports of other affected sites, including the uterus. Invasion into the cardiac structures is exceedingly rare.
The only established treatment for angioleiomyoma is surgical resection.
Show Notes - The Tall Tail Heart: Angioleiomyoma – The Christ Hospital
Syncope
Syncope is a transient loss of consciousness secondary to reduced blood flow to the brain. Often, certain presentations are mislabeled as syncope, such as seizure disorders, posttraumatic loss of consciousness, and cataplexy.
An organized diagnostic approach should be used to reduce hospital admissions and medical costs and increase diagnostic accuracy.
Syncope can be divided into five general subgroups.
1) Neurally mediated reflex syncope (carotid sinus syndro...
350. GLP-1 Agonists: Mechanisms to Applications with Dr. Dennis Bruemmer
Dec 19, 2023
Calling all those with a passion for cardiovascular prevention! In this episode of the CardioNerds Cardiovascular Prevention Series, we take a deep dive into the world of glucagon-like peptide-1 (GLP-1) receptor agonists. Along the way, you’ll hear about the biology of the GLP-1 molecule and its related peptides, learn more about how GLP-1 agonists promote glycemic control, weight loss, and cardiometabolic health, and explore the current body of literature supporting the individualized application of these medications to patients with diabetes, obesity, and/or ASCVD.
Join Dr. Christian Faaborg-Andersen (CardioNerds Academy Fellow and Internal Medicine Resident at MGH), Dr. Gurleen Kaur (Director of the CardioNerds Internship, Chief of House Einthoven, and Internal Medicine resident at BWH), and Dr. Rick Ferraro (CardioNerds Academy House Faculty and Cardiology Fellow at JHH) for a wide-ranging discussion on GLP-1 and GIP agonists with Dr. Dennis Bruemmer (Cardiologist and Director of the Center for Cardiometabolic Health in the section of Preventive Cardiology at the Cleveland Clinic).
Show notes were drafted by Dr. Christian Faaborg-Andersen. Audio editing was performed by CardioNerds Academy Intern, student Dr. Tina Reddy.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
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Pearls and Quotes - GLP-1 Agonists: Mechanisms to Applications
The selection and dosing of GLP-1 and GIP agonists (GLP-1s and GIPs) depends on their intended use as an anti-glycemic or anti-obesity agent.
The cardiovascular benefits of GLP-1s and GIPs may be independent of improvements in glycemic control, and in part be driven by reduction in inflammation, a key driver of arterial plaque formation.
In patients with comorbid coronary artery disease, obesity, and diabetes, GLP-1 agonists and SGLT-2 inhibitors should be used as first-line agents, over metformin.
Tirzepatide is a dual agonist that activates GIP and GLP-1 receptors. GIP is highly expressed in the brain, which may mediate satiety, promote energy expenditure, and enhance peripheral glucose metabolism.
Caution should be used with GLP-1 agonists in patients with long-standing diabetes complicated by gastroparesis, as well as incompletely treated diabetic retinopathy.
GI upset is not uncommon with GLP-1/GIP agonists, and switching to a different agonist is unlikely to help.
Show notes - GLP-1 Agonists: Mechanisms to Applications
What are the mechanisms of action by which GLP-1 and GIP controls blood sugar and body weight?
Glucagon-like peptide-1 (GLP-1) is an endogenous hormone that is secreted in response to an oral glucose load. It promotes insulin release, inhibits glucagon secretion, and slows gastric emptying via the brain-intestine axis, leading to satiety. GLP-1 agonists are medications that mimic the effect of this hormone and, on average, lower hemoglobin A1C by 0.8% to 1.5%. These medications include semaglutide, liraglutide, and dulaglutide.
Glucose-dependent insulinotropic polypeptide (GIP) is also an endogenous hormone, similarly secreted by the body in response to an oral glucose load such as a meal. GIP is highly expressed in the arcuate nucleus and hypothalamus, which may mediate satiety, promote energy expenditure, and enhance peripheral glucose metabolism. Tirzepatide is a dual GLP-1/GIP agonist.
What is the role of GLP-1/GIP agonists in patients with overweight/obesity and/or type 2 diabetes? How does the dosing of GLP-1/GIP medications change with their intended disease target?
349. Case Report: Into the Thick of It – An Unusual Cause of Hypertrophic Cardiomyopathy – Cleveland Clinic
Dec 17, 2023
CardioNerds cofounder Dr. Amit Goyal and cardiology fellows from the Cleveland Clinic (Drs. Alejandro Duran Crane, Gary Parizher, and Simrat Kaur) discuss the following case: A 61-year-old man presented with symptoms of heart failure and left ventricular hypertrophy. He was given a diagnosis of obstructive hypertrophic cardiomyopathy. He eventually underwent septal myectomy, mitral valve replacement, aortic aneurysm repair, and aortic valve replacement with findings of Fabry’s disease on surgical pathology. The case discussion focuses on the differential diagnosis for LVH and covers Fabry disease as an HCM mimic. Expert commentary was provided by Dr. Angelika Ewrin. The episode audio was edited by student Dr. Diane Masket.
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Case Media - An Unusual Cause of Hypertrophic Cardiomyopathy – Cleveland Clinic
Pearls - An Unusual Cause of Hypertrophic Cardiomyopathy – Cleveland Clinic
Left ventricular hypertrophy is a cardiac manifestation of several different systemic and cardiac processes, and its etiology should be clarified to avoid missed diagnosis and treatment opportunities.
Fabry disease is a rare, X-linked inherited disease that can present cardiac and extra-cardiac manifestations, the former of which include hypertrophic cardiomyopathy, conduction defects, coronary artery disease, conduction abnormalities, arrhythmias, and heart failure.
The diagnosis of Fabry disease includes measurement of alpha-galactosidase enzyme activity as well as genetic testing to evaluate for pathogenic variants or variants of unknown significance in the GLA gene. Family members of patients diagnosed with Fabry disease should be screened based on the inheritance pattern.
Multimodality imaging can be helpful in the diagnosis of Fabry disease. Echocardiography can show left ventricular hypertrophy (LVH), reduced global strain, aortic and mitral valve thickening, and aortic root dilation with associated mild to moderate aortic regurgitation. Cardiac MRI can show hypertrophy of papillary muscles, mid-wall late gadolinium enhancement and low-native T1 signal.
The treatment of Fabry disease involves a multi-disciplinary approach with geneticists, nephrologists, cardiologists, nephrologists, and primary care doctors. Enzyme replacement therapy can delay the progression of cardiac disease.
Show Notes - An Unusual Cause of Hypertrophic Cardiomyopathy – Cleveland Clinic
What are the causes of left ventricular hypertrophy?
LVH is extremely common. It is present in 15-20% of the general population, and is more common in Black individuals, the elderly, obese or hypertensive individuals, with most cases being secondary to hypertension and aortic valve stenosis. In general terms, it is helpful to divide the causes of LVH into three main groups: high afterload states, obstruction to LV ejection, and intrinsic myocardial problems. Increased afterload states include both primary and secondary hypertension and renal artery stenosis. Mechanical obstruction includes aortic stenosis, subaortic stenosis, and coarctation of the aorta. Lastly, several intrinsic problems of the myocardium can cause LV hypertrophy, such as athletic heart with physiological LVH, hypertrophic cardiomyopathy with or without outflow obstruction, and infiltrative or storage diseases such as cardiac amyloidosis, Fabry’s disease, or Danon disease, among others.
How does Fabry disease present?
Fabry disease is present in all races and is an X-linked lysosomal storage disorder caused by pathogenic variants in the GLA gene that result in reduced alpha-galactosidase enzyme activity,
348. Case Report: An Interesting Intersection of Cardiology and Hematology/Oncology – Guthrie Robert Packer Hospital
Dec 08, 2023
CardioNerds (Daniel Ambinder) joins Dr. Priyanka Ghosh and Dr. Ahmad Lone from the Guthrie Robert Packer Hospital for a day in the Finger Lakes region of New York. They discuss the following case. A 35-year-old man with nonspecific symptoms of headache, fatigue, and chest wall pain was found to have elevated troponin levels, elevated inflammatory markers, EKG with inferior and anterolateral ST depressions, and no obstructive coronary artery disease on cardiac catheterization. His peripheral eosinophilia, cardiac MRI results, and bone marrow biopsy revealed eosinophilic myocarditis from acute leukemia with eosinophilia. This episode discusses this rare type of myocardial inflammation, its potential causes, and the diagnostic workup with the mention of how this patient was ultimately treated for his acute leukemia and myocarditis. Expert commentary is provided by Dr. Saurabh Sharma. Audio editing by CardioNerds academy intern, student doctor Pace Wetstein.
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Case Media - Guthrie Robert Packer Hospital
Pearls - Guthrie Robert Packer Hospital
Myocarditis, especially eosinophilic myocarditis, requires a high level of clinical suspicion.
Eosinophilic myocarditis should be considered in a patient presenting with chest pain, normal coronary arteries, and pronounced eosinophilia levels.
Causes of eosinophilic myocarditis can vary, and diagnosis requires a thorough, detailed history, which cannot be determined many times.
Treatment of eosinophilic myocarditis focuses on the underlying etiology, acute management, and therapy for concomitant heart failure or cardiomyopathy.
Consider the whole-patient and cardiac manifestations of non-cardiac illnesses.
Show Notes - Guthrie Robert Packer Hospital
What is eosinophilic myocarditis?
Eosinophilic myocarditis is a type of myocardial inflammation involving eosinophilic cell infiltration and an entity that is likely under-recognized. It requires a high level of suspicion as, many times, patients may not initially present with peripheral eosinophilia, which may develop over the course of their disease process. The presentation can vary from mild cardiac injury to fulminant cardiogenic shock depending on the degree of infiltration and concurrent other organ involvement. The presentation can include heart failure symptoms as well as electrical conduction abnormalities.
How is eosinophilic myocarditis diagnosed?
Eosinophilic myocarditis is diagnosed by a thorough history including new medications, exposures, travel, prior allergy history, physical exam, lab work including a complete blood count differential, inflammatory markers, cardiac biomarkers, and cardiac diagnostics which should include a 12-lead ECG and transthoracic echocardiogram as well as potentially cardiac MRI and/or endomyocardial biopsy.
What are the causes of eosinophilic myocarditis?
The causes of eosinophilic myocarditis include medication-induced, hypersensitivity reactions, infections, malignancy, and immune-mediated disorders such as eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes. The hypersensitivity subtype has been reported to be the most common cause. Potential offending medications can include antibiotics, sulfonamides, anticonvulsants, anti-inflammatory medications, and diuretics.
What is the treatment for eosinophilic myocarditis?
Treatment for eosinophilic myocarditis is multi-faceted, including focusing on the etiology and withdrawal of any potential offending agents, management of the acute clinical presentation, and treatment of any concomitant heart failure or cardiomyopathy.
347. Case Report: Heartmate 3 with a Side of Mustard – Medical University of South Carolina
Nov 30, 2023
CardioNerds (Dr. Josh Saef and Dr. Sumeet Vaikunth) join Dr. Sheng Fu, Dr. Payton Kendsersky, and Dr. Aniqa Shahrier from the Medical University of South Carolina for some off-shore fishing. They discuss the following featuring a patient with D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3. Expert commentary was provided by Dr. Brian Houston. The episode audio was edited by student Dr. Adriana Mares.
A 39-year-old woman with a history of D-transposition of the great arteries (D-TGA) with prior atrial switch repair (Mustard) was admitted from the clinic with cardiogenic shock. She underwent right heart catheterization which demonstrated elevated biventricular filling pressures and low cardiac index. An intra-aortic balloon pump was placed, and the patient was evaluated for advanced therapies. A liver biopsy showed grade 3 fibrosis, which, in combination with her shock state, made her a high-risk candidate for isolated heart or combined heart-liver transplantation. After a multi-disciplinary discussion, the patient underwent a Heartmate III left ventricular assist device (LVAD) implant in her systemic right ventricle. Although she did well post-operatively, she was admitted after a month with recurrent cardiogenic shock, with imaging showing her inflow cannula had become perpendicular to the septum. The patient and family eventually decided to pursue comfort measures, and the patient passed.
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Case Media - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3
Pearls - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3
Early diagnosis of cyanotic congenital heart disease is paramount for treatment and prevention of future complications.
Adult congenital heart disease requires a multi-disciplinary team for management in consultation with an adult congenital cardiology specialist.
Eisenmenger syndrome is related to multiple systemic complications and has a high rate of mortality.
Advancement in PAH medical management can offer noninvasive treatment options for some patients.
Transthoracic echocardiography is the cornerstone for diagnosis. Other modalities (e.g. cardiac CT, cardiac MRI, invasive catheterization) can aid in diagnosis and management.
Pearls - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3
While advances in pediatric surgery have allowed many patients born with congenital heart disease to survive into adulthood, adult congenital heart disease (ACHD) patients are complex and prone to numerous adverse sequalae including arrhythmias, heart failure, valvular disease, and non-cardiac organ dysfunction.
Heart failure can be a challenging presentation in ACHD patients due to a longstanding history of clinical compensation.
Their unique and complex anatomy, as well as highly variable clinical presentation, present unique challenges when it comes to advanced heart failure options such as durable left ventricular assist devices (LVAD) or transplantation.
While durable LVAD implantation is possible in patients with systemic right ventricles, anatomic compatibility is paramount and poses ongoing challenges in their management.
Goals of care discussions should be had early, as options for treatment may be limited.
Show Notes - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3
What are some common sequelae in ACHD patients?
ACHD patients are a heterogeneous population, but atrial tachycardias are extremely frequent in this patient population, often due to re-entrant pathways around surgical suture lines. These can often be treated with radiofrequency ablation while paying clos...
346. CardioOncology: Disparities in CardioOncology – Towards Health Equity with Dr. Javier Gomez-Valencia
Nov 26, 2023
CardioNerds co-founder Dr. Dan Ambinder, series chair Dr. Giselle Suero Abreu, and episode FIT Lead Dr. Rachel Ohman discuss disparities in cardiooncology with Dr. Javier Gomez Valencia, the Director of Cardio-Oncology services at John H. Stronger Jr. Hospital of Cook County. Dr. Rachel Ohman drafted show notes. Audio editing by student doctor Shivani Reddy.
A disproportionate burden of both cancer and cardiovascular disease affects racial and ethnic minority groups as well as lower-income communities. Similar patterns of vulnerability exist among cancer survivors with cardiovascular disease, although further investigation in these subpopulations is needed. We discuss a comprehensive approach to the cardio-oncology patient, our current understanding of the social and structural determinants of disparities in cardio-oncology populations, and other contributions to inequity in the field. Given the growing population of cancer survivors and limited accessibility to cardio-oncology specialists, these topics are of critical importance to anyone caring for cancer patients who have or are at risk for cardiovascular disease.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Disparities in CardioOncology
Social and structural determinants of health are drivers of cardiovascular and cancer disparities. Existing data on cardiotoxicity outcomes suggests these determinants also contribute to disparities in cardio-oncology.
Assessing social and structural determinants of health should be a routine part of evaluating a patient with an active or prior history of cancer.
Customs, country of origin, and immigration status matter. Differential risk profiles among Hispanic/Latinx sub-populations require further investigation.
Black patients, particularly black women with breast cancer, have elevated morbidity and mortality from cardiotoxicity. Data suggest contributions from social determinants of health.
Representation in clinical trials must be diversified for applicability to our diverse patient populations. Concerted efforts should be made to recruit diverse clinical trial participants and help patients from diverse communities effectively participate in the research process, contributing to the advancement of science.
Show notes - Disparities in CardioOncology
How do you approach the evaluation of a new patient in cardio-oncology? How do social and structural determinants of health impact treatment-associated cardiotoxicity?
The evaluation of a new patient should include an assessment of a patient’s intrinsic risk factors, risks associated with cancer treatment, and consideration of cardioprotective therapeutic strategies
Social and structural vulnerabilities should also be assessed routinely as a part of risk stratification. Providers should take stock of a patient’s demographic (e.g., race/ethnicity, gender), socioeconomic (e.g., occupation, insurance status, food security, housing security), environmental (e.g., transportation, proximity to health resources, neighborhood safety), and sociocultural (e.g., psychosocial stressors, discrimination, acculturation) determinants that are in turn modulated by larger systemic forces like structural racism.
This comprehensive risk assessment can guide the strategies to mitigate cardiovascular risk before, during, and after cancer treatment.
What barriers to cardio-oncology care are unique to the Hispanic/Latinx popula...
345. Case Report: A Case of Unrepaired Congenital Heart Disease – University of Chicago – Northshore University
Nov 22, 2023
CardioNerds (Dr. Josh Saef, Dr. Agnes Koczo) join Dr. Iva Minga, Dr. Kifah Hussain, and Dr. Kevin Lee from the University of Chicago - NorthShore to discuss a case of unrepaired congenital heart disease that involves D-TGA complicated by Eisenmenger syndrome. The ECPR was provided by Dr. Michael Earing. Audio editing by Dr. Akiva Rosenzveig.
A 25-year-old woman with an unknown congenital heart disease that was diagnosed in infancy in Pakistan presents to the hospital for abdominal pain and weakness. She is found to be profoundly hypoxemic, and an echocardiogram revealed D-transposition of the great arteries (D-TGA) with a large VSD. As this was not repaired in childhood, she has unfortunately developed Eisenmenger syndrome with elevated pulmonary vascular resistance. She is stabilized and treated medically for her cyanotic heart disease. Unfortunately given the severity and late presentation of her disease, she has limited long-term options for care. CardioNerds discuss the diagnosis of D-TGA and Eisenmenger’s syndrome, as well as long-term management and complications associated with this entity.
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Case Media - Unrepaired Congenital Heart Disease
Pearls - Unrepaired Congenital Heart Disease
Early diagnosis of cyanotic congenital heart disease is paramount for treatment and prevention of future complications.
Adult congenital heart disease requires a multi-disciplinary team for management in consultation with an adult congenital cardiology specialist.
Eisenmenger syndrome is related to multiple systemic complications and has a high rate of mortality.
Advancement in PAH medical management can offer noninvasive treatment options for some patients.
Transthoracic echocardiography is the cornerstone for diagnosis. Other modalities (e.g. cardiac CT, cardiac MRI, invasive catheterization) can aid in diagnosis and management.
Show Notes - Unrepaired Congenital Heart Disease
Cyanotic congenital heart disease is often diagnosed in infancy and timely treatment is paramount. As these diseases progress over time, pulmonary over-circulation often pulmonary hypertension (PH), elevated pulmonary vascular resistance, and Eisenmenger syndrome will develop, which preclude definitive treatment. For D-TGA, before PH develops, there are surgical options such as the arterial switch procedure that can treat the disease. Unfortunately, once Eisenmenger syndrome develops, there are multiple systemic complications including hyperviscosity, thrombosis, bleeding, kidney disease, iron deficiency, arrhythmias, etc. that can occur. Management requires a multi-disciplinary team including an adult congenital cardiology specialist, but mortality rates remain high, with median survival reduced by 20 years, worse with complex cardiac defects. Bosentan is a first line treatment for patients with Eisenmenger syndrome, with PDE-5 inhibitors as a second line either by themselves or in combination with bosentan. Data are currently limited for latest-generation PH treatments in Eisenmenger syndrome and further study is still underway.
References
Ferencz C. Transposition of the great vessels. Pathophysiologic considerations based upon a study of the lungs. Circulation. 1966 Feb;33(2):232-41.
Arvanitaki A, Gatzoulis MA, Opotowsky AR, Khairy P, Dimopoulos K, Diller GP, Giannakoulas G, Brida M, Griselli M, Grünig E, Montanaro C, Alexander PD, Ameduri R, Mulder BJM, D'Alto M. Eisenmenger Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022 Mar 29;79(12):1183-1198.
Earing MG, Webb GD. Congenital heart disease and pregnancy: maternal and fetal risks. Clin Perinatol.
344. Beyond the Boards: Disease of the Peripheral Arteries with Dr. Amy Pollak
Nov 17, 2023
CardioNerds (Drs. Amit Goyal, Jason Feinman, and Tiffany Dong) discuss Beyond the Boards: Diseases of the Peripheral Arteries with Dr. Amy Pollak. We review common presentations of peripheral vascular disease, ranging from aortic disease to the more distal vessels in an engaging case-based discussion. Dr. Pollack talks us through these cases, including the diagnosis and management of peripheral vascular diseases. Show notes were drafted by Dr. Matt Delfiner and episode audio was edited by student doctor Tina Reddy.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
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Pearls and Quotes - Disease of the Peripheral Arteries
Risk factors for abdominal aortic aneurysm include traditional atherosclerotic risk factors such as age, hypertension, hyperlipidemia, and tobacco use.
Screening for AAA should be for men over the age of 65 years with a history of tobacco use. If present, medical management includes blood pressure and lipid lowering therapies to decrease the risk of expansion. Decision for surgical intervention relies on size and rate of growth of AAA, with clear indications if it grows> 10 mm in a year or diameter of 5.5 cm in men and 5.0 cm in women.
When diagnosis of PAD is not straightforward (presence of symptoms but ABI is normal), an exercise ankle-brachial index (ABI) test can be useful. An exercise-induced decrease in ABI by 20% or in ankle pressure by 30 mmHg is consistent with PAD.
For PAD, treatment with low dose rivaroxaban and aspirin yields lower event rates than with antiplatelet therapy alone. This in combination with lifestyle therapies (diet + exercise) and risk factor management (hypertension and hyperlipidemia) are the cornerstones of therapy. Revascularization is indicated for continued PAD symptoms despite conservative therapy.
Acute limb ischemia is an “acute leg attack” and is a life-threatening emergency. Common symptoms include pain, pallor, pulselesess, parasthesias, cold temperature (poikilothermia), and paralysis. Restoration of blood flow is paramount, and emergent or urgent revascularization is the first line therapy for those with symptoms < 2 weeks.
Notes - Disease of the Peripheral Arteries
Learning Objectives:
Describe screening and therapeutic strategy for AAA management.
Understand the risk factors and diagnosis of peripheral arterial disease.
Compare different management approaches for PAD.
Be able to recognize acute limb ischemia.
Describe the overall treatment strategy for acute limb ischemia.
Abdominal Aortic Aneurysms
Abdominal aortic aneurysms are a source of high morbidity and mortality. The US Preventative Services Task Force recommends one time screening ultrasound for AAA in men older than 65 years of age with a tobacco use history. Risk factors include age, hypertension, hyperlipidemia, and tobacco use. Patients with AAA between 3-3.9 mm should be monitored every 2-3 years. Sizes 4-5 cm should be re-imaged every 6-12 months. Additional screening can be done for individuals < 65 years who have a first degree relative with AAA.
Women are more likely to have aortic dissection at smaller diameters than men, which is why intervention (open vs endovascular repair) is recommended at 5 cm diameter for women versus at 5.5 cm for men. Additionally, repair is also warranted if a AAA grows more than 5 mm in 6 months or 10 mm in one year.
Risk factor management is key with AAA, including blood pressure, glucose, and lipid targeting. The presence of an AAA should be treated as secondary ASCVD prevention like coronary a...
343. Cardio-Oncology: Arrhythmias in CardioOncology with Dr. Michael Fradley
Nov 01, 2023
CardioNerds (Dr. Daniel Ambinder, Dr. Giselle Suero Abreu, Dr. Kahtan Fadah, and Dr. Colin Blumenthal) discuss arrhythmias in CardioOncology with Dr. Michael Fradley.
In this episode, Dr. Michael Fradley joins us in the CardioNerds CardioOncology clinic where he uses his unique dual training in cardio-oncology and electrophysiology to walk us through the complex interplay and management of these disorders. We discuss the incidence and pathophysiology of these arrhythmias, including the link with various cancer treatments, screening and detection, and complex management including rate vs rhythm control in atrial fibrillation, need for anticoagulation, effects on the QTc and so much more. Given the unique challenges with this population we also delve into how this affects their oncology care and how to approach changes to their cancer treatment.
Show notes were drafted by Dr. Kahtan Fadah and episode audio was edited by student Dr. Tina Reddy.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Arrhythmias in CardioOncology
Arrhythmias are common in cancer patients due to shared risk factors and bi-directional risk between cardiac and oncologic disorders. Many cancer therapeutics can be directly arrhythmogenic or lead to cardiotoxicities that pre-dispose to arrhythmias.
Though incidence of arrhythmia can be significant increased with some cancer therapeutics (e.g. ibrutinib), there is not specific data to support proactive ambulatory monitoring for arrhythmia without evidence of clear symptoms.
Atrial fibrillation is the most common arrhythmia in cancer patients and management of atrial fibrillation, as well as other tachyarrhythmias, is unchanged from management in non-cancer patients. General principles of when to start anticoagulation or rate vs rhythm control are not significantly different (e.g. still use CHA2DS2-VAsC, monitor for symptoms etc), but providers should be more mindful of drug-drug interactions with cancer therapeutics.
Cancer therapeutics as well as common medications used to treat side effects or complications (e.g. antiemetics, antibiotics, etc) can prolong the QT interval and increase risk of Torsades de pointes (TdP). The QTc should be monitored with an ECG for patients on these medications. If a patient does develop a serious arrhythmia like TdP, management is similar to that in non-cancer patients.
The goal of arrhythmia management in cardio-oncology is to prevent cardiovascular disease from becoming a barrier to appropriate cancer therapy. Though cancer therapeutics should be temporarily or permanently discontinued in potentially fatal events (e.g TdP from QTc prolonging meds), the overall goal is to manage the arrhythmias appropriately to allow cancer therapeutics to be continued or restarted.
Show notes - Arrhythmias in CardioOncology
What is the prevalence of arrhythmias in patients with cancer?
Arrhythmias are common in patients with cancer due to a multitude of factors. Atrial fibrillation is the most common arrhythmia in this population and occurs in approximately 5% of patients with cancer. The driving forces are multifactorial and include the direct arrhythmogenic effects of cancer therapeutics and cardiotoxicities of cancer therapeutics that make arrhythmogenesis more likely. Additionally, there is a bi-directional link between cancer and cardiac disorders. For example, not only is atrial fibrillation more common in patien...
342. Case Report: A Young Woman With Recurrent ACS – National University Heart Centre Singapore
Oct 30, 2023
CardioNerds join Dr. Tony Li Yi Wei, Dr. Rodney Soh Yu Hang, and Dr. Zan Ng Zhe Yan from the National University Heart Centre Singapore for a cocktail drink on the top of marina bay sands. They discuss the following case featuring a young woman with recurrent ACS ultimately found to have Takayasu Arteritis. The ECPR for this episode is provided by Dr. Teng Gim Gee and Professor Tan Huay Cheem. Episode audio was edited by student Dr. Shivani Reddy.
A 37-year-old woman presents with chest pain. She has a background history of Hashimoto thyroiditis, gestational diabetes, and anemia of chronic disease and possible iron deficiency. Her significant medical history includes ischemic heart disease with prior coronary angiogram showing triple vessel coronary artery disease for which she underwent coronary artery bypass graft surgery (CABG) with LIMA-LAD, SVG-OM, SVG-RCA. After CABG, she had recurrent admissions in the subsequent year with acute coronary syndromes where she underwent percutaneous coronary intervention (PCI) to SVG-OM, RI, proximal LAD, and distal LAD. She was a non-smoker and had been compliant with her medications. For her current presentation, she underwent myocardial perfusion imaging which showed a large sized area of inducible ischemia in the LCx territory. Repeat coronary evaluation showed occluded SVG-OM, occluded LIMA-LAD where she underwent PCI. Clinically, she was noted to have weak brachial and radial pulses on the left side with systolic blood pressure difference between both arms. CT Thoracic Angiogram demonstrated concern for underlying large vessel vasculitis such as Takayasu arteritis. ESR was elevated at 34. Rheumatology was consulted and she was diagnosed with Takayasu arteritis and started on prednisolone and azathioprine. Given her young age, absence of traditional atherosclerotic risk factors, and progressive coronary disease, Takayasu arteritis was deemed the underlying etiology of her coronary disease.
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Case Media - Recurrent ACS
Pearls - Recurrent ACS
Approach to accelerated CAD and/or CAD in the young: Causes of MI in young patients can be divided into four groups, although a considerable overlap exists between all groups. (1) atheromatous CAD, (2) non-atheromatous process such as spontaneous coronary artery dissection, vasculitides such as Takayasu disease, (3) hypercoagulable states leading to recurrent arterial and venous thrombosis and/or thromboembolism, and (4) recreational drug use.
Clinical Presentation of Takayasu and prevalence of cardiac involvement: Takayasu’s arteritis is classified as a large-vessel vasculitis because it primarily affects the aorta and its primary branches. It has a worldwide distribution; however, the greatest prevalence is seen in Asia. Women are affected in 80 to 90 percent of cases, with an age of onset that is usually between 10 and 40 years.
Management of Takayasu arteritis: As for systemic anti-inflammatory therapy, the mainstay of treatment would be systemic glucocorticoids guided by the care of a rheumatologist. A steroid sparing agent may be given in conjunction for long term suppressive therapy to achieve longer-term disease control. The choice of additional agents depends on several factors including considerations regarding comorbidities, a patient's plans for conceiving a child, cost of treatments, and availability of specific agents. Options include methotrexate, azathioprine as well as mycophenolate. There are also growing studies into anti-TNF-alpha agents such as etanercept or infliximab.
Show Notes - Recurrent ACS
341. Guidelines: 2021 ESC Cardiovascular Prevention – Question #35 with Dr. Melissa Tracy
Oct 26, 2023
The following question refers to Section 4.9 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD fellow Dr. Patrick Azcarate, and then by expert faculty Dr. Melissa Tracy.
Dr. Tracy is a preventive cardiologist, former Director of the Echocardiography Lab, Director of Cardiac Rehabilitation, and solid organ transplant cardiologist at Rush University.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #35
In patients with a low risk of cardiovascular disease, which of the following is true?AAspirin does not affect the risk of ischemic strokeBAspirin increases the risk of fatal bleeding.CAspirin reduces the risk of non-fatal MI.DAspirin reduces cardiovascular mortality
Answer #35
ExplanationIn 2019, an updated meta-analysis of aspirin for primary prevention of cardiovascular events found that patients with a low risk of CVD taking aspirin did not have a reduction in all-cause or cardiovascular mortality. There was a lower risk of non-fatal MI (RR 0.82) and ischemic stroke (RR 0.87). However, aspirin was also associated with a higher risk of major bleeding (RR 1.50), intracranial bleeding (RR 1.32), and major GI bleeding (RR 1.52). There was no difference in the risk of fatal bleeding (RR 1.09).Accordingly, the ESC does not recommend antiplatelet therapy in individuals with low/moderate CV risk due to the increased risk of major bleeding (Class III, LOE A).Although aspirin should not be given routinely to patients without established ASCVD, we cannot exclude that in some patients at high or very high CVD risk, the benefits may outweigh the risks.Main TakeawayIn patients with low/moderate risk of CVD, aspirin for primary prevention is not recommended due to the higher risk of bleeding. For those at higher risk of CVD, low-dose aspirin may be considered for prevention in the absence of contraindications.Guideline Loc.Section 4.9.1, Page 3291
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340. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #30 with Dr. Shashank Sinha
Oct 25, 2023
The following question refers to Section 8.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by University of Southern California cardiology fellow and CardioNerds FIT Trialist Dr. Michael Francke, and then by expert faculty Dr. Shashank Sinha.
Dr. Sinha is an Assistant Professor of Medical Education at the University of Virginia School of Medicine and an advanced heart failure, MCS, and transplant cardiologist at Inova Fairfax Medical Campus. He currently serves as both the Director of the Cardiac Intensive Care Unit and Cardiovascular Critical Care Research Program at Inova Fairfax. He is also a Steering Committee member for the multicenter Cardiogenic Shock Working Group and Critical Care Cardiology Trials Network and an Associate Editor for the Journal of Cardiac Failure, the official Journal of the Heart Failure Society of America.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #30
Ms. V. Tea is a 55-year-old woman with a history of cardiac sarcoidosis, heart failure with mildly reduced ejection fraction (HFmrEF – EF 40%), and ventricular tachycardia with CRT-D who presents with recurrent VT. She has undergone several attempts at catheter ablation of VT in the past and previously had been trialed on amiodarone which was discontinued due to hepatotoxicity. She now continues to have episodic VT requiring anti-tachycardia pacing and ICD shocks despite medical therapy with mexiletine, metoprolol, and sotalol. Her most recent PET scan showed no active areas of inflammation. Currently, her vital signs are stable, and labs are unremarkable. What is the best next step for this patient?
A
Evaluation for heart transplant
B
Evaluation for LVAD
C
Dobutamine
D
Prednisone
E
None of the above
Answer #30
Explanation
The correct answer is A – evaluation for heart transplant.
For selected patients with advanced heart failure despite GDMT, cardiac transplantation is indicated to improve survival and quality of life (Class 1, LOE C-LD). Heart transplantation, in this context, provides intermediate economic value.
Clinical indicators include refractory or recurrent ventricular arrhythmias with frequent ICD shocks. Patient selection for heart transplant includes assessment of comorbidities, goals of care, and various other factors. The United Network of Organ Sharing Heart Transplant Allocation Policy was revised in 2018 with a 6-tiered system to better prioritize unstable patients and minimize waitlist mortality. VT puts the patient as a Status 2 on the transplant list. There was a contemporary analysis of patients with end-stage cardiomyopathy due to cardiac sarcoidosis, published in Journal of Cardiac Failure, in 2018 that demonstrated similar 1-year and 5-year survival after heart transplant between patients with and without cardiac sarcoidosis.
Choice B (evaluation for LVAD) is incorrect. While bridge to transplant with LVAD is definitely a potential next step in patients with cardiac sarcoidosis, it is not recommended in patients presenting primarily with refractory ventricular arrhythmias due to granuloma-induced scarring. In this situation, patients benefit from direct heart transplant rather than bridge to transplant LVAD approa...
339. ACHD: Electrophysiology in ACHD with Dr. Frank Fish
Oct 25, 2023
CardioNerds (Amit Goyal and Daniel Ambider) ACHD series co-chair Dr. Daniel Clark (Vanderbilt University), cardiology FIT lead Dr. Stephanie Fuentes (Houston Methodist Hospital), and Dr. Frank Fish, a Pediatric Electrophysiologist and the Director of the Pediatric Electrophysiology (EP) Lab at Monroe Carrell Jr Children’s Hospital at Vanderbilt University. He is a board certified Adult Congenital Heart Disease (ACHD) physician and has a wealth of experience performing EP procedures in adults living with congenital heart disease. Audio editing was performed by student Dr. Shivani Reddy.
In this episode, we discuss key concepts and management of electrophysiologic issues that we can encounter when caring for adults with congenital heart disease. Arrythmias in adults with congenital heart disease can be intrinsic due to the defect itself or as a consequence of the interventions that they have undergone to palliate and/or repair these defects. The complex anatomy of these patients and the years of pressure and volume load make them not only exquisitely hemodynamically sensitive to arrhythmias (that may otherwise not be of much consequence to the general population) but they also make interventions (catheter ablation or device implant) complex. We therefore embark in a case-based discussion of patients with ACHD (Fontan circulation, Ebstein’s anomaly and Tetralogy of Fallot) in an effort to highlight the presentation of arrythmias and the management strategy in this very important group of patients.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
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Pearls - Electrophysiology in ACHD
Patients with Fontan circulation have a high risk of developing atrial (and ventricular) arrhythmias and they are highly sensitive to the hemodynamic consequences that these arrythmias ensue. The goal of therapy then should be to achieve sinus or atrial paced rhythm. Rate control should NOT the goal.
Patients with Ebstein’s anomaly have high arrhythmic potential. They can have multiple accessory pathways (especially right sided) which can in turn be associated with sudden cardiac death. We should have low threshold for EPS +/- catheter ablation in patients with WPW pattern.
Patients with Tetralogy of Fallot have a unique risk for SCD that warrant ICD implant apart from the standard criteria (LVEF <=35% and NYHA II-III symptoms). This involves the pump (RV dilation/dysfunction), electricity (QRSd>180 ms) and surgical repair approach.
Patient’s anatomy is the major consideration when implanting devices (PPM/ICD). We ought to assess for residual intracardiac shunt at the atrial level and consider closing if feasible prior to placing a device. CRT has merit in systemic LV but less so in systemic RV.
Notes- Electrophysiology in ACHD
What should we know about atrial arrhythmias in a Fontan patient?
Intraatrial re-entrant tachycardia (IART) is slower than typical atrial flutter with atrial rates generally
338. Digital Health: Tips for the Digital Health Innovator with Dr. David Cho and Dr. Francoise Marvel
Oct 23, 2023
Join CardioNerds Co-Founder Dr. Dan Ambinder, Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital and Johns Hopkins Bayview) join Digital Health Experts, Dr. Francoise Marvel (Co-Founder of Corrie Health and Co-Director of Johns Hopkins Digital Health Lab) and Dr. David Cho (Chair of the ACC Health Care Innovation Council) for another installment of the Digital Health Series. In this specific episode, we discuss pearls, pitfalls and everything in between for the emerging digital health innovator. This series is supported by an ACC Chapter Grant in collaboration with Corrie Health. Notes were drafted by Dr. Karan Desai. Audio editing was performed by student Dr. Shivani Reddy.
In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients.
This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Pearls and Quotes - Tips for the Digital Health Innovator
A critical first step in developing a digital health intervention is defining the clinical problem rather than developing the technology itself.
Most digital transformations – whether in medicine or other industries – require several iterations for the technology to develop and demonstrate value. A key aspect of this iterative process was human-centered design: involving patients, their families, and other end-users early in the development of the digital health intervention.
Dr. Marvel and colleagues have developed a 6-step process for innovators to consider in taking a concept to product.
Notes - Tips for the Digital Health Innovator
In this episode, we discussed with Dr. Marvel and Dr. Cho some general concepts on how to develop digital health interventions (DHI). DHIs have a broad definition, including any software or hardware application used to improve access, quality, efficacy or efficiency and they exist in various modalities (e.g., text message, mobile apps, wearables).
Dr. Marvel has previously authored a roadmap for digital health intervention that provides guidance for an interdisciplinary approach to developing effective and evidence-based DHIs. As discussed on the episode, a critical first step is defining the clinical problem an innovator is attempting to solve instead of attempting to develop the technology solution first and then adapting it to the problem.
Drs. Marvel and Cho emphasized that most digital transformations – whether in medicine or other industry – require several iterations for the technology to develop and demonstrate value. Frequent assessment in a structured manner will help the intervention mature over time. Dr. Marvel noted that a key aspect of this iterative process was human-centered design: involving patients...
337. Beyond the Boards: The Diagnosis and Management of Infective Endocarditis with Dr. Michael Cullen
Oct 17, 2023
CardioNerds (Drs. Amit Goyal, Matthew Delfiner, and Tiffany Dong) discuss infective endocarditis with distinguished clinician-educator Dr. Michael Cullen. We dive into the nuances of infective endocarditis, including native valve endocarditis, prosthetic valve endocarditis, and right-sided endocarditis.
Notes were drafted by Dr. Tiffany Dong, and audio editing was performed by student Dr. Adriana Mares.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
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Pearls and Quotes
The physical exam is crucial in the evaluation of infective endocarditis and includes cardiac auscultation and a search for sequelae of endocarditis, such as immunologic and embolic phenomena.
The modified Duke Criteria categorizes the diagnosis of infective endocarditis into four different buckets: definite endocarditis by pathology, definite endocarditis by clinical criteria, possible endocarditis, and rejected.
The diagnosis of endocarditis may involve several different imaging modalities, including transthoracic echocardiogram, transesophageal echocardiogram, 4D CT, and nuclear imaging.
For left-sided endocarditis, indications to operate include endocarditis due to S. aureus or fungi, heart failure, evidence of perivalvular complications, persistent bacteremia, and large vegetations.
The management of endocarditis often involves multiple teams, including cardiology, infectious disease, addiction medicine, neurology, anesthesiology, and cardiothoracic surgery.
Notes
What signs/complications of endocarditis are apparent on physical exam and labs?
A new or worsening cardiac murmur with possible signs of volume overload.
Vascular phenomena encompass splinter hemorrhages, conjunctival hemorrhages, Janeway lesions, mycotic aneurysms, and TIA/strokes.
Immunologic phenomena include glomerulonephritis, Roth spots, and Osler nodes.
Positive blood cultures with 2-3 samples collected.
Elevated inflammatory markers.
How does the modified Duke criteria assist in the diagnosis of infective endocarditis?
The modified Duke criteria separate the diagnosis of endocarditis into four categories: definite endocarditis by pathology, definite endocarditis by clinical criteria, possible endocarditis, and rejected endocarditis.
Definitive endocarditis by pathology requires pathologic confirmation of “bugs under the microscope.”
Definitive endocarditis by clinical criteria requires two major criteria, one major and two minor criteria, or all five minor criteria.
Possible endocarditis requires one major and one minor or three minor criteria.
Major criteria:Positive blood culture for typical organism
Evidence of endocardial involvement (e.g., vegetation on echo)
Minor CriteriaPredisposing clinical factors (e.g., intravenous drug use, known valvulopathy)FeverImmunologic phenomenaVascular phenomena
Blood culture for atypical organism
What is the role of TTE compared to TEE in endocarditis?
TTE and TEE both have their roles in the workup for endocarditis.
TTE can provide a baseline screen and yield a better understanding of ventricular size and function than transesophageal.
The strength of TEE is the ability to visualize smaller vegetations along with perivalvular complications that may be missed on TTE.
If clinical suspicion is high for endocarditis, repeat echocardiography is warranted.
What are other tools to evaluate for endocarditis in prosthetic valves?
TTE and TEE remain important and should be commonly utilized for the diagnosis of endocarditis.
336. Guidelines: 2021 ESC Cardiovascular Prevention – Question #34 with Dr. Eileen Handberg
Oct 10, 2023
The following question refers to Section 4.7 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Shivani Reddy, answered first by NP Carol Patrick, and then by expert faculty Dr. Eileen Handberg.Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President Elect for the PCNA.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #34
Ms. BW presents after her best friend was diagnosed with hypertension and is interested in measuring her own blood pressure. According to the ESC Guidelines, what BP screening approach is recommended for making a diagnosis of hypertension? ARepeated measurements in one visitBA single measurement in a single visitCRepeated measurements in more than one visit DReported patient history
Answer #34
Explanation The correct answer is C – Repeated measurements in more than one visit.It is recommended to base the diagnosis of hypertension on repeated office BP measurements on more than one visit except when hypertension is severe (e.g., Grade 3—defined as SBP > 180 and/ or DBP >110mmHg—and especially in high-risk patients) (Class I, LOE C). In addition to recommending repeat measurements across visits, the guidelines provide a number of considerations for appropriately measuring blood pressure, such as taking measurements when seated in a quiet environment for 5 minutes and measuring in both arms at the first visit and using the higher-level value arm for visits thereafter (see Table 14 on page 3283).Additionally, home blood pressure monitoring is recommended as an alternative to repeated office measurements. Blood pressure measurements are taken with a semiautomated, validated cuff for 3 consecutive days – and 6-7 days being preferred – in the morning and at night, averaged over that period. Notably, home blood pressure thresholds for the diagnosis of hypertension are lower than for that of in-office measurements, with a daytime systolic of 135mmHg or diastolic of 85mmHg given as the level at which hypertension is diagnosed, as opposed to 140mmHg and 90mmHg for systolic and diastolic levels, respectively, given for in-office diagnosis.Main TakeawayWith the exception of those with severely elevated blood pressures, the diagnosis of hypertension requires repeated measurements across multiple office visits.Guideline Loc.Sections 4.7.1 and 4.7.2, Table 13 and 14, Figure 14
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335. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #29 with Dr. Michelle Kittleson
Oct 05, 2023
The following question refers to Section 7.8 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Stony Brook University Hospital medicine resident and CardioNerds Intern Dr. Chelsea Tweneboah, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy Chief Dr. Teodora Donisan, and then by expert faculty Dr. Michelle Kittleson.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #29
A 69-year-old man was referred to the cardiology clinic after being found to have a reduced left ventricular ejection fraction and left ventricular hypertrophy. For the last several months he has been experiencing progressively worsening fatigue and shortness of breath while getting to the 2nd floor in his house. He has a history of bilateral carpal tunnel syndrome and chronic low back pain. He takes no medications. On exam, his heart rate is 82 bpm, blood pressure is 86/60 mmHg, O2 saturation is 97% breathing ambient air, and BMI is 29 kg/m2. He has a regular rate and rhythm with normal S1 and S2, bibasilar pulmonary rales, and 1+ pitting edema in both legs. EKG shows normal sinus rhythm with a first-degree AV delay and low voltages. Transthoracic echocardiogram shows a moderately depressed LVEF of 35-39%, severe concentric hypertrophy with a left ventricular posterior wall thickness of 1.5 cm and strain imaging showing globally reduced longitudinal strain with apical sparring. There is also biatrial enlargement and a small pericardial effusion. A pharmacologic nuclear stress test did not reveal any perfusion defects. A gammopathy panel including SPEP, UPEP, serum and urine immunofixation studies, and serum free light chains are unrevealing. A 99mTc-Pyrophosphate scan was positive with grade 3 uptake. In addition to starting diuretics, what is the next most appropriate step for managing for this patient?
A
Start metoprolol succinate
B
Start sacubitril/valsartan
C
Perform genetic sequencing of the TTR gene
D
Perform endomyocardial biopsy
Answer #29
Explanation
The correct answer is C – perform genetic sequencing of the TTR gene.
This patient has findings which raise suspicion for cardiac amyloidosis. There are both cardiac (low voltages on EKG and echocardiogram showing marked LVH with biatrial enlargement and small pericardial effusion as well as a characteristic strain pattern) and extra-cardiac (bilateral carpal tunnel syndrome and low back pain) features to suggest amyloidosis. The diagnosis of cardiac amyloidosis requires a high index of suspicion and most commonly occurs due to a deposition of monoclonal immunoglobulin light chains (AL-CM) or transthyretin (ATTR-CM). ATTR may cause cardiac amyloidosis as either a pathogenic variant (ATTRv) or as a wild-type protein (ATTRwt).
Patients for whom there is a clinical suspicion for cardiac amyloidosis should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains (Class 1, LOE B-NR). Immunofixation electrophoresis (IFE) is preferred because serum or urine plasma electrophoresis (SPEP or UPEP) are less sensitive. Together, measurement of serum IFE, urine IFE, and serum FLC is >99% sensitive for AL amyloidosis.
334. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #28 with Dr. Gregg Fonarow
Sep 27, 2023
The following question refers to Section 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Palisades Medical Center medicine resident & CardioNerds Academy Fellow Dr. Maryam Barkhordarian, answered first by Hopkins Bayview medicine resident & CardioNerds Academy Faculty Dr. Ty Sweeny, and then by expert faculty Dr. Gregg Fonarow.
Dr. Fonarow is the Professor of Medicine and Interim Chief of UCLA's Division of Cardiology, Director of the Ahmanson-UCLA Cardiomyopathy Center, and Co-director of UCLA's Preventative Cardiology Program.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #28
Mr. Gene D’aMeTi, a 53-year-old African American man with ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 30-35%), is recently admitted with acutely decompensated heart failure and acute kidney injury on chronic kidney disease stage III. His outpatient regiment includes sacubitril-valsartan 97-103mg BID, carvedilol 25mg BID, and hydralazine 50mg TID.
Sacubitril-valsartan was held because of worsening renal function. Despite symptomatic improvement with diuresis, his renal function continues to decline. He is otherwise well perfused & with preservation of other end organ function.
Throughout this hospitalization, he has steadily become more hypertensive with blood pressures persisting in the 170s/90s mmHg. What would be an appropriate adjustment to his medication regimen at this time?
A
Resume Losartan only
B
Start Amlodipine
C
Increase current Hydralazine dose
D
Start Isosorbide dinitrate therapy
E
Both C & D
Answer #28
ExplanationThe correct answer is E – both increasing the current hydralazine dose (C) and starting isosorbide dinitrate therapy (D). Although ACEI/ARB therapy (choice A) has shown a mortality and morbidity benefit in HFrEF, caution should be used in patients with renal insufficiency. In this patient with ongoing decline in renal function, RAAS-inhibiting therapies (ACEi, ARB, ARNI, MRA) should be avoided. In this case, as his RAAS-I has been stopped, it would be reasonable to increase current therapies to target doses (or nearest dose tolerated), as these demonstrated both safety and efficacy in trials (Class 1, LOE A). Considering that his high dose ARNI was stopped, it is unlikely that either hydralazine or isosorbide dinitrate alone, even at maximal doses, would be sufficient to control his blood pressure (Options C and D, respectively). Interestingly, in the original study by Massie et. Al (1977), the decision was made to combine these therapies as the result was thought to be superior to either medication alone. ISDN would provide preload reduction, while Hydralazine would decrease afterload. Consequently, we do not have data looking at the individual benefit of either medication in isolation. In self-identified African Americans with NYHA class III or IV HFrEF already on optimal GDMT, the addition of hydralazine & isosorbide dinitrate is recommended to improve symptoms and reduce mortality and morbidity (Class 1, LOE A). In this case, as the patient has evidence of progressive renal disfunction, we are limited in using traditional RAAS-I, such as ACEI, ARB, or ARNI.
333. Cardio-Oncology: Thromboembolic Disease in Cardio-oncology with Dr. Joshua Levenson
Sep 26, 2023
In this episode, CardioNerds Dr. Daniel Ambinder, Dr. Giselle Suero Abreu, and Dr. Saahil Jumkhawala discuss thromboembolic disease in cardio-oncology with faculty expert Dr. Joshua Levenson, the Associate Program Director of the cardiology fellowship and an Assistant Professor of Medicine at the University of Pittsburg School of Medicine. Venous (VTE) and arterial thromboembolic (ATE) events are precipitants of morbidity and mortality in patients with cancer. Here, we discuss the pathophysiology of thromboembolism, risk factors and epidemiology for ATE and VTE, the role of risk prediction and patient stratification, and the approach to treatment for and prophylaxis of thromboembolic events with anticoagulation. Show notes were drafted by Dr. Saahil Jumkhawala and episode audio was edited by CardioNerds Intern Dr. Tina Reddy.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Thromboembolic Disease in Cardio-oncology
Patients with cancer are at higher risk of developing both arterial and venous thromboembolic events compared to the general population.
Certain cancer subtypes are associated with a relatively higher risk of developing thromboembolic complications.
Anticoagulation type and duration should be dependent on patient characteristics and risk factors, with shared decision-making between the patient and their providers.
Subgroups of patients may benefit from more aggressive management of their atherosclerotic cardiovascular risk factors while being treated for cancer to reduce the risk of thromboembolic complications.
Show notes - Thromboembolic Disease in Cardio-oncology
What are the incidence and main manifestations of thromboembolic events (venous and arterial) in patients with active malignancy?
Approximately 10% of outpatients with active cancer have venous thromboembolic events, many of which are asymptomatic. Clinically relevant VTEs are predominantly deep venous thrombosis (DVTs) with pain and/or swelling of the involved extremities or pulmonary emboli (PEs) resulting in chest pain and/or shortness of breath. VTE is the number one preventable cause of death for all hospitalized patients, and the ability to prevent and treat these events is crucial, particularly in high-risk populations such as patients with cancer.
Are there any high-risk associations with specific cancer subtypes?
Patients with metastatic disease and those receiving chemotherapy are more likely to develop arterial or venous thromboembolic events. Patients with acute myelogenous leukemia (AML) and thrombocytopenic patients are at the lowest risk for thromboembolic events. Multiple myeloma patients on medication such as proteasome inhibitors or lenalidomide appear at particular risk. Patients with localized, early-stage cancers such as breast, prostate, and melanoma are also at lower risk.
What are the main risk factors to identify patients at a higher risk of developing thrombotic complications?
Patients with a sedentary lifestyle, deconditioning, and undergoing active treatment with chemotherapy are at the highest risk of developing DVT or PE.
How should we approach choosing the optimal type and duration of anticoagulation for acute pulmonary embolism (PE) in the setting of malignancy?
This remains an area of active research. Historically, patients would receive systemic anticoagulation with heparin followed by warfarin.
332. Digital Health: Digital Health and Health Equity with Dr. LaPrincess Brewer
Sep 19, 2023
Join CardioNerds Co-Founder Dr. Dan Ambinder, Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital and Johns Hopkins Bayview) join Digital Health Expert, Dr. La Princess Brewer (Associate Professor of Medicine Mayo Clinic Rochester) for another installment of the Digital Health Series. In this specific episode, we discuss how digital health can both reduce and amplify health disparities. This series is supported by an ACC Chapter Grant in collaboration with Corrie Health. Notes were drafted by Dr. Karan Desai. Audio editing was performed by student Dr. Shivani Reddy.
In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients.
This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Pearls and Quotes
Digital redlining occurs when a particular group has limited access to key services based on race and ethnicity, perpetuating inequities. Throughout this podcast episode, Dr. Brewer emphasizes how community engagement early in the creation of digital health technologies can mitigate structural inequities.
Dr. Brewer spoke about methods to develop innovative digital health tools that are culturally sensitive and inclusive, specifically community-based participatory research (CBPR). In CBPR, community members are partners with researchers in each step of the intervention.
While certain individuals and communities may have physical access to digital health tools, they still may remain inaccessible for several reasons.
Notes
In this episode, we focus on achieving digital health equity and how the very technologies meant to reduce health disparities can widen them. We started by discussing a paper from Dr. Brewer and colleagues that crystallized how digital health disparities can occur with the example of Pokémon Go. As described in this paper, this mobile application was one of the most used applications worldwide. It incentivized users to collect virtual goods at various physical locations termed PokéStops. For public health professionals, this mobile app represented an engaging way to promote physical activity amongst users. However, some racial and ethnic minority groups in low-income, urban areas quickly took notice of the lack of PokéStops within their neighborhoods. As researchers noted, this could be considered examples of digital redlining, or limiting a particular group from key services based on race and ethnicity. As Dr. Brewer notes in the paper, the Pokémon Go developers relied on maps that were crowdsourced from a majority white male demographic. While it may not have been deliberate, the development process created a structural digital inequity placing certain communities at a home-cour...
331. Case Report: New Onset Murmur In A Pregnant Woman With A Mechanical Heart Valve – Oregon Health & Science University
Sep 12, 2023
CardioNerds co-founder Dr. Dan Ambinder joins CardioNerds join Dr. Pooja Prasad, Dr. Khoa Nguyen and expert Dr. Abigail Khan (Assistant Professor of Medicine, Division of Cardiovascular Medicine, School of Medicine) from Oregon Health & Science University and discuss a case of mechanical valve thrombosis. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.
A 23-year-old pregnant woman with a mechanical aortic valve presented to the maternal cardiac clinic for a follow-up visit. On physical exam, a loud grade three crescendo-decrescendo murmur was audible and transthoracic echocardiography revealed severely elevated gradients across the aortic valve. Fluoroscopy confirmed an immobile leaflet disk. Thrombolysis was successfully performed using a low dose ultra-slow infusion of thrombolytic therapy, leading to normal valve function eight days later.
Treatment options for mechanical aortic valve thrombosis include slow-infusion, low-dose thrombolytic therapy or emergency surgery. In addition to discussing diagnosis and management of mechanical valve thrombosis, we highlight the importance of preventing valve thrombosis during the hypercoagulable state of pregnancy with careful pre-conception counseling and a detailed anticoagulation plan.
See this case published in European Heart Journal - Case Reports.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
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Pearls - mechanical valve thrombosis
The hypercoagulable state of pregnancy presents a risk for women with mechanical heart valves with contemporary data estimating the rate of valve thrombosis during pregnancy at around 5%.
Thrombolytic therapy is a (relatively) safe alternative to surgery and should be considered first line for treatment of prosthetic valve thrombosis in all patients, especially in pregnant women.
Pre-conception counselling and meticulous anticoagulation management for patients with mechanical heart valves are key aspects of their care.
The evaluation for prosthetic valve thrombosis in pregnant persons requires a review of anti-coagulation history and careful choice of diagnostic testing to confirm the diagnosis and minimize risks to the parent and the baby.
Multi-disciplinary care with close collaboration between cardiology and obstetrics is critical when caring for pregnant persons with cardiac disease.
Show Notes - mechanical valve thrombosis
How can we counsel and inform women with heart disease who are contemplating pregnancy?
Use the Modified World Health Organization classification of maternal cardiovascular risk to counsel patients on their maternal cardiac event rate and recommended follow-up visits and location of delivery (local or expert care) if pregnancy is pursued.
To learn about normal pregnancy cardiovascular physiology and pregnancy risk stratification in persons with cardiovascular disease, enjoy CardioNerds Episode #111. Cardio-Obstetrics: Normal Pregnancy Physiology with Dr. Garima Sharma.
Adapted from the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy
What is the differential diagnosis for a new murmur in a pregnant person who has undergone heart valve replacement?
Normal physiology - elevated flow from hyperdynamic state and/or expansion of blood volume in pregnancy.
Pathologic - increased left ventricular outflow tract flow from turbulence of flow due to pannus ingrowth, new paravalvular leak, or obstructive mechanical disk motion from vegetation or thrombus.
What are diagnostic modalities for the evaluation of suspected prosthetic valve thrombosis?
The 2020 ACC/AHA guidelines gave a class I recommendation for evaluation of susp...
330. Guidelines: 2021 ESC Cardiovascular Prevention – Question #33 with Dr. Noreen Nazir
Sep 05, 2023
The following question refers to Section 4.5 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir.
Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #33
Mr. V is a 37-year-old man who presents to clinic after a recent admission for anterior STEMI and is status-post emergent percutaneous intervention to the proximal LAD. He has mixed hyperlipidemia and a 10 pack-year history of (current) tobacco smoking. Which of the following points related to tobacco use is LEAST appropriate for today’s visit?
A
Providing assessment and encouragement for smoking cessation, even if for only a 30-second “very brief advice” intervention.
B
Reviewing and offering pharmacotherapy support options for smoking cessation if Mr. V expresses readiness to quit today.
C
Recommending a switch from traditional cigarettes to e-cigarettes as a first step towards cessation, as e-cigarettes are safer for use.
D
Discussing that smoking cessation is strongly recommended for all patients, regardless of potential weight gain.
Answer #33
Explanation
Answer C is LEAST appropriate and therefore is the correct answer.
Answer C is not appropriate. Although e-cigarettes may be more effective than nicotine replacement therapy (NRT) for smoking cessation, the long-term effects of e-cigarettes on cardiovascular and pulmonary health are unknown. According to the 2019 ACC/AHA prevention guidelines, e-cigarettes may increase the risk of CV and pulmonary diseases; their use has been reportedly associated with arrhythmias and hypertension. Therefore, neither the ESC nor ACC/AHA suggest clinicians recommend e-cigarettes over traditional cigarettes to patients.
Answer A: Smoking cessation is one of the most effective CVD risk-lowering preventive measures, with significant reductions in (repeat) myocardial infarctions or death. ESC guidelines emphasize the importance of encouraging smoking cessation even in settings where time is limited. “Very brief advice” on smoking is a proven 30-second clinical intervention, developed in the UK, which identifies smokers, advises them on the best method of quitting, and supports subsequent quit attempts. While ESC does not explicitly suggest a frequency of assessment, the 2019 ACC/AHA guidelines specifically recommend that “all adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.”
Answer B: The ESC suggests (class 2) that offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered in smokers. A meta-analysis of RCTs in patients with ASCVD reflects that varenicline (RR 2.6), bupropion (RR 1.4), telephone therapy (RR 1.5), and individual counselling (RR 1.6) all increased quit rates versus placebo; NRT therapies were well-tolerated but had inconclusive effects on quit rates (RR 1.22 with 95% CI 0.72-2.06). The 2019 ACC/AHA recommendation to combine behavioral and pharmacotherapy interventions to maximize quit rates is a class 1 recommendation.
Answer D: The ESC gives a class 1 recommendation to recommending smoking cessation regardless of weight grain. Smokers who quit may expect an average weight gain of 5 kg, but the health benefits of tobacco cessation (both CVD and non-CVD related) consistently outweigh risks from weight...
329. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #27 with Dr. Randall Starling
Aug 30, 2023
The following question refers to Section 7.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Cleveland Clinic internal medicine resident and CardioNerds Intern Akiva Rosenzveig, answered first by UPMC Harrisburg cardiology fellow and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Randall Starling.
Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #27
Which of the following sentences regarding diuretics in the management of heart failure is correct?
A
In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes.
B
Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates.
C
The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms.
D
The maximum daily dose of furosemide is 300 mg.
Answer #27
Explanation
Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF.
Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival.
Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class...
328. ACHD: Eisenmenger Syndrome with Dr. Alexander Sasha Opotowsky
Aug 24, 2023
Eisenmenger syndrome is an end-stage complication of congenital heart disease that occurs when a left to right shunt causes pulmonary over-circulation, leading to vascular remodeling, increased vascular resistance, and ultimately even shunt reversal. Aside from cardiac complications, this pathology has unique complications secondary to chronic cyanosis. In this episode of CardioNerds co-founder Dr. Amit Goyal, ACHD series co-chair Dr. Josh Saef, and Dr. Khaled Tuwairqi (ACHD cardiologist at King Faisal / Elite Hospitals) join Dr. Alexander (Sasha) Optowsky (Director of the Adult Congenital Heart Disease Program at Cincinnati Childrens) to discuss diagnosis and management of Eisenmenger syndrome. Show notes were drafted by Dr. Anna Scandinaro and episode audio was edited by CardioNerds Academy Intern Dr. Akiva Rosenzveig.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
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Pearls - Eisenmenger Syndrome
First described in 1897 by Victor Eisenmenger, Eisenmenger syndrome is a long-term complication of unrepaired left to right shunts, resulting from pulmonary vascular remodeling and pulmonary hypertension. This eventually leads to reversal of the shunt, with right to left flow causing cyanosis.
Evaluation for Eisenmenger syndrome should include a comprehensive history, physical exam, ECG, echocardiogram, cardiac catheterization, and laboratory work to identify multi-system complications of cyanosis and secondary erythrocytosis.
The most definitive means to diagnose Eisenmenger syndrome in a patient with a prior left-to-right shunt lesion is with a right heart cardiac catheterization showing right to left shunting (Qp:Qs < 1).
Eisenmenger syndrome is a multi-organ disease and many manifestations occur due to secondary erythrocytosis. Prevention and treatment of these complications are the major goals of care in this population. Complications of Eisenmenger syndrome include gout, bilirubin gallstones, stroke, paraganglioma/pheochromocytoma, thrombophilia, retinal changes, hypertrophic osteoarthropathy, and kyphoscoliosis.
Emergency non-cardiac complications of Eisenmenger syndrome include cerebral abscess and hemoptysis.
Pregnancy is contraindicated in Eisenmenger syndrome due to high maternal and fetal mortality.
Notes- Eisenmenger Syndrome
1. How does Eisenmenger syndrome develop? Does everyone with a left-to-right shunt develop it? Can it develop as an iatrogenic complication?
The pulmonary vasculature is not used to seeing the increased flow it receives in the context of a left to right shunt. Over time this leads to an increase in pulmonary vascular resistance and pulmonary hypertension. When pulmonary pressures exceed systemic pressures, this causes shunt reversal with right to left shunting causing deoxygenated blood to cross from right side of the heart to the left side bypassing the lungs and causing cyanosis.
The process of developing Eisenmenger syndrome is chronically progressive and so adaptive changes have time to occur. Not all persons with unrepaired shunts will develop Eisenmenger syndrome ...
327. Cardio-Oncology: Interventional CardioOncology with Dr. Cezar Iliescu
Aug 18, 2023
CardioNerds CardioOncology Series Co-Chairs, Dr. Teodora Donisan and Dr. Dinu Balanescu, and FIT Lead Dr. Bala Pushparaji discuss Interventional CardioOncology with Prof. Cezar Iliescu.
In this episode, we discuss the spectrum of cardiovascular diseases encountered by the interventional onco-cardiologist, with a focus on nuances in endovascular therapies tailored to cancer patients and their unique comorbidities and complications. We also discuss certain special scenarios seen in the critically ill cancer patient, such as chronic thrombocytopenia, and how they alter standard of care compared to non-cancer patients.
Show notes were drafted by Dr. Bala Pushparaji and episode audio editing was performed by Dr. Akiva Rosenzveig.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
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Pearls and Quotes - Interventional CardioOncology
Cancer should be treated as a chronic illness akin to hypertension or diabetes and should not deprive patients from receiving appropriate cardiovascular treatment if otherwise indicated (e.g., PCI for acute coronary syndromes, etc.).
In cancer patients with stable angina, along with maximizing medical therapy, multimodality imaging (CTA/PET), intravascular imaging (IVUS/OCT), and physiologic testing (iFR/FFR) should be used routinely to prevent unnecessary stenting.
Caution is required in the cath lab for the cancer patient with thrombocytopenia. Techniques include utilizing micropuncture access, transfusing appropriate blood products based on thromboelastogram (TEG), and adjusting antiplatelet therapy regimens and duration.
Transcatheter aortic valve replacement (TAVR) is now the recommended treatment for most cancer patients with symptomatic/severe aortic stenosis and, if otherwise indicated, should preferably be pursued prior to cancer treatment to optimize the patient’s cardiovascular fitness and tolerance of anti-cancer therapy.
Pericardiocentesis in the cancer patient should be performed preferably under fluoroscopy with echocardiography and vascular ultrasound guidance (“triple guidance”).
Show notes - Interventional CardioOncology
What is the general approach to cardiovascular illness in the cancer patient?
Cancer and cardiovascular diseases share numerous risk factors. In addition, cancer and cancer therapies can be atherogenic, by means of inducing pro-inflammatory and hyprecoagulable states, increasing the risk of ischemic heart disease, stroke, and peripheral arterial disease.1
In the outpatient setting, emphasis should be placed on optimizing cardiovascular risk factors and improving overall cardiovascular fitness by exercising, having a healthy diet, and having regular sleep hours as these favor survivorship after cancer treatment. Questions to be answered in the clinic are - Is the patient cardiovascularly fit? Will the patient’s heart withstand cancer treatment? Is there concern for coronary artery disease, valvular disease, pericardial disease, or pulmonary hypertension?
Risk assessment and treatment for cancer patients with suspected or known cardiovascular disease should generally follow established ACC/AHA guidelines, with special considerations as outlined by the Society of Cardiovacular Angiography and Interventions (SCAI).2
Pre-chemotherapy cardioprotection for patients without coronary artery disease (CAD) with prophylactic beta-blockers, ACEi/ARB, and statins should be considered when appropriate.
326. Guidelines: 2021 ESC Cardiovascular Prevention – Question #32 with Dr. Michael Wesley Milks
Aug 16, 2023
The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks.Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center, where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology's Cardiovascular Disease Prevention Leadership Council.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #32
Mr. Daniel Collins is a 58-year-old man with hypertension, chronic kidney disease (CKD), and obesity who presents to your clinic for a routine physical examination. Vitals are as follows: BP 143/79 mmHg, HR 89 bpm, O2 99% on room air, weight 106 kg, BMI 34.5 kg/m2. Recent laboratory testing revealed: creatinine 1.24 mg/dL, total cholesterol 203 mg/dL, HDL 39 mg/dL, LDL 112 mg/dL, TG 262 mg/dL. His current medications include lisinopril and rosuvastatin. You recommend increasing the dose of lisinopril to treat uncontrolled hypertension. What additional step(s) are indicated at this visit?
A
Order urine albumin-to-creatinine ratio
B
Ask the patient how often they have been bothered by trouble falling or staying asleep, or sleeping too much
C
Perform depression screening
D
All of the above
Answer #32
Explanation The correct answer is D – all of the above.Answer A is correct. The ESC gives a Class I (LOE C) indication that all CKD patients, with or without diabetes, should undergo appropriate screening for ASCVD and kidney disease progression, including monitoring for changes in albuminuria. Cardiovascular disease is the leading cause of morbidity and death among patients with CKD. Even after adjusting for risk factors, including diabetes and hypertension, there is a linear increase in CV mortality with decreasing GFR below ~60-75 mm/min/1.73m2. Specific CKD-related risk factors include uremia-mediated inflammation, oxidative stress, and vascular calcification.Answer choice B is also correct. In patients with ASCVD, obesity, and hypertension, the ESC gives a Class I (LOE C) indication to regularly screen for non-restorative sleep by asking the question related to sleep quality as follows: “‘How often have you been bothered by trouble falling or staying asleep or sleeping too much?”. Additionally, if there are significant sleep problems that are not responding within four weeks to improving sleep hygiene, referral to a specialist is recommended (Class I, LOE C). However, despite the strong association of OSA with CVD, including hypertension, stroke, heart failure, CAD, and atrial fibrillation, treatment of OSA with CPAP has failed to improve hard CVD outcomes in patients with established CVD. Interventions that focus on risk factor modification, including reduction of obesity, alcohol intake, stress, and improvement of sleep hygiene, are important.Answer choice C is also correct. The ESC gives a Class I (LOE C) recommendation that mental health disorders with either significant functional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. All mental disorders are associated with the development of CVD and reduced life expectancy. Additionally, the onset of CVD is associated with an approximately 2-3x increased risk of mental health disorders compared to a ...
325. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #26 with Dr. Eldrin Lewis
Aug 14, 2023
The following question refers to Section 4.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Rochester General Hospital cardiology fellow and Director of CardioNerds Journal Club Dr. Devesh Rai, and then by expert faculty Dr. Eldrin Lewis.Dr. Lewis is an Advanced Heart Failure and Transplant Cardiologist, Professor of Medicine and Chief of the Division of Cardiovascular Medicine at Stanford University. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #26
A 45-year-old man presents to cardiology clinic to establish care. He has had several months of progressive dyspnea on exertion while playing basketball. He also reports intermittent palpitations for the last month. Two weeks ago, he passed out while playing and attributed this to exertion and dehydration. He denies smoking and alcohol intake.
Family history is significant for sudden cardiac death in his father at the age of 50 years. Autopsy has shown a thick heart, but he is unaware of the exact diagnosis. He has two children, ages 12 and 15 years old, who are healthy.
Vitals signs are blood pressure of 124/84 mmHg, heart rate of 70 bpm, and normal respiratory rate. On auscultation, a systolic murmur is present at the left lower sternal border. A 12-lead ECG showed normal sinus rhythm with signs of LVH and associated repolarization abnormalities. Echocardiography reveals normal LV chamber volume, preserved LVEF, asymmetric septal hypertrophy with wall thickness up to 16mm, systolic anterior motion of the anterior mitral valve leaflet with 2+ eccentric posteriorly directed MR, and resting LVOT gradient of 30mmHg which increases to 60mmHg on Valsalva.
You discuss your concern for an inherited cardiomyopathy, namely hypertrophic cardiomyopathy. In addition to medical management of his symptoms and referral to electrophysiology for ICD evaluation, which of the following is appropriate at this time?
A
Order blood work for genetic testing
B
Referral for genetic counseling
C
Cardiac MRI
D
Coronary angiogram
E
All of the above
Answer #26
Explanation
The correct answer is B – referral for genetic counseling.
Several factors on clinical evaluation may indicate a possible underlying genetic cardiomyopathy. Clues may be found in:
· Cardiac morphology – marked LV hypertrophy, LV noncompaction, RV thinning or fatty replacement on imaging or biopsy
· 12-lead ECG – abnormal high or low voltage or conduction, and repolarization, altered RV forces
· Presence of arrhythmias – frequent NSVT or very frequent PVCs, sustained VT or VF, early onset AF, early onset conduction disease
· Extracardiac features – skeletal myopathy, neuropathy, cutaneous stigmata, and other possible manifestations of specific syndromes
In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members (Class 2a, LOE B-NR). In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to ...
324. Case Report: Silent Compression Until it Becomes Salient – Boston University
Aug 10, 2023
CardioNerds co-founder Dr. Dan Ambinder joins Dr. Abdelrhman Abumoawad, Dr. Leili Behrooz from the Boston University Vascular Medicine over hot chocolate in Boston. They discuss two interesting cases of lower extremity edema caused by May-Thurner syndrome. Dr. Naomi Hamburg (Professor of Vascular Medicine and Cards at BU/BMC) provides the ECPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig.
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Case Synopses - May-Thurner syndrome
Case 1: A 34-year-old woman with HIV on HAART presenting with left leg swelling and non-healing new foot ulcer for 3 months. She works as a cashier. On exam, her BMI is 35 kg/m2 and there are intact pulses bilaterally. Her left leg has varicose veins in the territory of the great saphenous vein, hyperpigmentation, edema, and a foot ulcer. Her right leg appears normal. Venous Duplex ultrasonography showed chronic partially occlusive thrombus in the left common femoral and profunda femoral veins and decreased doppler respiratory variation on the left side. She was treated with debridement and compression therapy for ulcer healing. She was referred to vascular surgery and underwent contrast venography that demonstrated collateral circulation from the left lower extremity (LE) to the right lower extremity, and stenotic lesion at the left common iliac vein (LCIV). She was diagnosed with May-Thurner syndrome, and a venous stent was placed, and the patient was started on aspirin 81 mg daily for 6 months.
Case 2: A 71-year-old man presented with left lower extremity pain and edema. He underwent a left lower extremity venous Duplex ultrasound that showed chronic thrombus in the left proximal to distal femoral vein and acute thrombus in the left popliteal vein and was started on anticoagulation (AC). The patient was also having palpitations and was found to have paroxysmal atrial fibrillation. He underwent pulmonary vein isolation during which it was noted that his LCIV was subtotally occluded. He underwent CT venogram which showed lumbosacral osteophytic compression of the LCIV known as bony May-Thurner syndrome. Given minimal symptoms, the decision was made not to pursue interventional options and to manage conservatively with AC which the patient needs regardless.
Case Media - May-Thurner syndrome
Pearls - May-Thurner syndrome
An often under-recognized, but treatable cause of DVT is left common iliac vein compression known as May-Thurner syndrome.
Most patients who have May-Thurner anatomy are asymptomatic. Only a minority of patients with the May-Thurner anatomy present with symptoms such as left leg edema/pain and DVT.
Young women are at a higher risk of developing May-Thurner syndrome compared to men.
A high degree of suspicion is needed to investigate patients with unilateral left-sided leg symptoms and venous duplex features of May-Thurner syndrome.
The diagnosis is made with non-invasive imaging including venous duplex, CT/MR venography, intravascular Ultrasound (IVUS), and catheter-based venography.
Although IVUS is the gold standard for diagnosis, due to its invasive nature, it has been replaced by CT/MR imaging.
Treatment includes anticoagulation if a thrombus is present. Most patients receive venous stenting at the obstructed site to prevent compression of the left common iliac vein. Some patients need catheter-directed thrombolysis prior to stent placement.
Show Notes -May-Thurner syndrome
What is May-Thurner syndrome?
Classic May-Thurner syndrome is venous outflow obstruction due to external compression of the left common iliac vein by the right common iliac arte...
323. Beyond the Boards: Complications of Acute Myocardial Infarction with Dr. Jeffrey Geske
Aug 08, 2023
CardioNerds co-founder Dr. Amit Goyal and episode leads Dr. Jaya Kanduri (FIT Ambassador from Cornell University) and Dr. Jenna Skowronski (FIT Ambassador from UPMC) discuss Complications of acute myocardial infarction with expert faculty Dr. Jeffrey Geske. They discuss various complications of acute MI such as cardiogenic shock, bradyarrythmias, left ventricular outflow tract obstruction, ruptures (papillary muscle rupture, VSD, free wall rupture), and more. Show notes were drafted by Dr. Jaya Kanduri. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
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Pearls and Quotes - Complications of Acute Myocardial Infarction
Sinus tachycardia is a “harbinger of doom”!
The triad for RV infarction includes hypotension, elevated JVP, and clear lungs. These patients are preload dependent and may need fluid resuscitation despite having an elevated JVP.
Bradyarrythmias in inferior MIs are frequently vagally mediated. The focus should be on medical management before committing to a temporary transvenous pacemaker, such as reperfusion, maintaining RV preload and inotropy, avoiding hypoxia, and considering RV-specific mechanical circulator support (MCS).
Worsening hypotension with inotropic agents (e.g., dobutamine, epinephrine, dopamine, norepinephrine) after a large anterior-apical MI should raise suspicion for dynamic left ventricular outflow tract obstruction due to compensatory hyperdynamic basal segments.
The myocardium after a late presentation MI is as “mushy as mashed potatoes”! Need to look out for papillary muscle rupture, VSD, and free wall rupture as potential complications. Papillary muscle rupture can occur with non-transmural infarcts, and often presents with flash pulmonary edema. VSDs will have a harsh systolic murmur and are less likely to present with pulmonary congestion. Free wall rupture can present as a PEA arrest. All of these complications require urgent confirmation on imaging and early involvement of surgical teams.
Notes - Complications of Acute Myocardial Infarction
How should we approach cardiogenic shock (CS) in acute myocardial infarction (AMI)?
Only 10% of AMI patients present with CS, but CS accounts for up to 70-80% of mortality associated with AMI, usually due to extensive LV infarction with ensuing pump failure.
Physical examSinus tachycardia is considered a “harbinger of doom”, when the body compensates for low cardiac output by ramping up the heart rateThe presence of sinus tachycardia and low pulse and/or blood pressure in a patient with a large anterior MI should raise suspicion for cardiogenic shockBe wary of giving IV beta blockers in this situation as negative inotropes can precipitate cardiogenic shock (Commit Trial)
When interpreting a patient’s blood pressure in the acute setting, it is helpful to know their baseline blood pressure and if they have a significant history of hypertension.
Patients <75 years of age with CS have improved survival at 6 months and at 1 year with early revascularization (SHOCK trial)
Mechanical circulatory supportIntra-aortic balloon pump (IABP)No mortality benefit with IABP use in CS at 30 days and at 1 year (IABP-SHOCK II trial)ACC/AHA guidelines give IABP a class IIa recommendation for medically refractory AMI-CS in the USA, whereas the ESC guidelines give it a class III recommendation.Percutaneous left ventricular assist device (Impella)No difference in mortality between IABP or Impella use after 30 days or 6 months (IMPRESS trial)Howev...
322. Guidelines: 2021 ESC Cardiovascular Prevention – Question #31 with Dr. Eugene Yang
Aug 06, 2023
The following question refers to Figures 6-8 from Sections 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.Dr. Yang is Professor of Medicine at the University of Washington where he is also the Medical Director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and as well as former Chair of the ACC Prevention of CVD Section. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #31
The 2021 ESC CV Prevention guidelines recommend a stepwise approach to risk stratification and treatment options. What is the first step in risk factor treatment regardless of past medical history, risk factors, or established ASCVD?AInitiate statin for goal LDL <100 mg/dlBAssess family history of premature CVDCCounsel on ketogenic dietDStop smoking and lifestyle recommendations
Answer #31
ExplanationThe correct answer is D – stop smoking and lifestyle recommendations. Smoking cessation and lifestyle modifications are recommended for everyone across the spectrum of ASCVD risk including for both primary and secondary prevention (Class 1). It is worth noting that many patients can move themselves towards a lower risk category without taking drugs just by stopping smoking.Option A is incorrect. While initiating statin therapy for goal LDL <100 mg/dL may be an appropriate treatment option for some patients, it is not the first step per the “stepwise approach” recommended in the ESC guidelines. Whether or not to initiate a statin depends on a multitude of factors including estimated 10-year CVD risk, age, comorbidities, established ASCVD, and patient preference. The first step for patients with established ASCVD includes LDL-C reduction to goal <70 mg/dL (class I) with intensification to a goal LDL-C <55mg/dL based on residual 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities, frailty, and patient preference. Primary prevention of ASCVD first targets LDL-C goal <100 (class IIa) in appropriately selected patients.Option B is incorrect. While assessing family history of premature CVD should be part of an initial evaluation and certainly considered a risk enhancing factor, it is not a modifiable risk factor with regards to treatment.Option C is incorrect. A ketogenic diet is not endorsed nor recommended by ACC/AHA or ESC.Studies have shown the benefit of a stepwise approach to treatment intensification. Attainment of treatment goals is similar, side effects are fewer, and patient satisfaction is significantly greater with such an approach. It is not recommended to stop assessment of treatment goals after the first step.Main TakeawayA stepwise approach to treatment intensification is recommended. The first steps for all patients are to stop smoking and institute lifestyle recommendations.Guideline Loc.· 3.2.3 Figures 6-8
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321. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #25 with Dr. Mark Drazner
Aug 06, 2023
The following question refers to Sections 6.1 and 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & former CardioNerds Intern Hirsh Elhence, answered first by Greater Baltimore Medical Center medicine resident and CardioNerds Academy Fellow Dr. Alaa Diab, and then by expert faculty Dr. Mark Drazner.
Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the past President of the Heart Failure Society of America.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #25
A 50-year-old man with a history of type 2 diabetes mellitus, persistent atrial fibrillation, coronary artery disease with prior remote percutaneous coronary intervention, and ischemic cardiomyopathy with HFrEF (LVEF 38%) presents to your outpatient clinic. He denies dyspnea on exertion, orthopnea, bendopnea, paroxysmal nocturnal dyspnea, or peripheral edema. His heart rate is irregularly irregular at 112 beats per minute and blood pressure is 112/67 mmHg. Routine laboratory studies reveal a hemoglobin A1c of 7.7%. Which of the following medications should not be used to control this patient’s comorbidities?
A
Metoprolol succinate
B
Verapamil
C
Dapagliflozin
D
Pioglitizone
E
Both B and D
Answer #25
Explanation
The correct answer is E – both verapamil and pioglitazone should be avoided here.
Both verapamil and pioglitizone are associated with harm in patients with LVEF < 50% (Class 3: Harm). Verapamil and diltiazem are non-dihydropyridine calcium channel blockers. These medications can cause negative inotropic effects through inhibition of calcium influx and may be harmful in this patient population. Pioglitizone belongs to a class of diabetic medications known as the thiazolidinediones. This class of medications may increase the risk of fluid retention, heart failure, and hospitalization in patients with LVEF of less than 50%.
Metoprolol succinate, and other evidence-based beta blockers, have a Class 1 recommendation for patients with reduced ejection fraction ≤ 40% to prevent symptomatic heart failure and reduce mortality. It may additionally help with rate control in this patient with atrial fibrillation and rapid ventricular response.
SGLT2 inhibitors including dapagliflozin have a Class I recommendation for patients with symptomatic chronic HFrEF to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes (Class 1, LOE A). They also have a Class I recommendation in patients with type 2 diabetes and either established CVD or at high cardiovascular risk to prevent hospitalization for HF (Class 1, LOE A). Our patient has asymptomatic, or pre-HF (Stage B) heart failure with poorly controlled diabetes, and so use of an SGLT2 inhibitor would be appropriate.
Main Takeaway
Non-dihydropyridine calcium channel blockers and thiozolidinediones
both have Class 3 recommendations for harm in patients with reduced LV systolic dysfunction.
Guideline Loc.
Section 6.1 and 7.3
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320. TAVR and Stroke with Dr. Samir Kapadia
Aug 04, 2023
Stroke is a potentially devastating TAVR complication. In this episode, CardioNerds (Drs. Amit Goyal, Nikolaos Spilias, Ahmed Ghoneem, and Chelsea Amo-Tweneboah) discuss TAVR and stroke risk, stroke prevention strategies, and future directions with Dr. Samir Kapadia, Department chair and chief, Cardiovascular Medicine at Cleveland Clinic. They also discuss device innovation and randomized controlled trial implementation for testing device safety and efficacy. Audio editing by CardioNerds Academy Intern, Dr. Chelsea Amo Tweneboah.
As an adjunct to this episode and for a deeper review of cerebral embolic protection devices, read “Cerebral Embolic Protection Devices: Current State of the Art” by Agrawal, Kapadia et al., in US Cardiology Review.
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References - TAVR and Stroke
Leon MB, Smith CR, Mack M, et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. New England Journal of Medicine. 2010;363(17):1597-1607.
Kapadia SR, Makkar R, Leon M, et al. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. New England Journal of Medicine. 2022;387(14):1253-1263.
Kapadia SR, Kodali S, Makkar R, et al. Protection Against Cerebral Embolism During Transcatheter Aortic Valve Replacement. Journal of the American College of Cardiology. 2017;69(4):367-377.
Khan MZ, Zahid S, Khan MU, et al. Use and outcomes of cerebral embolic protection for transcatheter aortic valve replacement: A US nationwide study. Catheter Cardiovasc Interv. 2021;98(5):959-968.
319. Case Report: Caring for the Middle Child of Pulmonary Embolism – Texas Heart Institute
Jul 28, 2023
CardioNerds cofounders Dr. Amit Goyal and Dr. Daniel Ambinder join Dr. Isabel Balachandran, Dr. Diego Celli from the Texas Heart Institute. They discuss the nuances of risk stratification management of intermediate risk pulmonary embolism. The ECPR for this episode was provided by Dr. Alam Mahboob (Associate Professor of Medicine at Baylor College of Medicine and the Department of Medicine and Associate Program Director for the Cardiovascular Disease Fellowship Program at Baylor). Audio editing by CardioNerds Academy Intern, Dr. Chelsea Amo Tweneboah.
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Case Media - Caring for the Middle Child of Pulmonary Embolism – Texas Heart Institute
Pearls - Caring for the Middle Child of Pulmonary Embolism – Texas Heart Institute
Submassive pulmonary embolism is defined as an intermediate risk group of acute pulmonary embolism, which presents with signs of RV dysfunction and myocardial injury without hemodynamic instability.
The AHA, ACCP, and ESC have variable definitions of submassive PE. Non-invasive tools such as EKG, TTE, and CT are critical to defining RV dysfunction. The Pulmonary Embolism Severity Index (PESI) score is a validated tool to help risk stratify patients with PE.
Advanced therapies for submassive PE include systemic thrombolysis, catheter-based intervention, surgical embolectomy, and mechanical circulatory support. The decision between these therapies is based on individual patient risk profiles, local expertise, and the risk of major bleeding.
There is a spectrum of long-term complications after an acute PE, ranging from post PE syndrome to CTEPH (chronic thromboembolic pulmonary hypertension) caused by a maladaptive vascular remodeling from residual thrombus or arteriopathy. Thrombolytic therapies are still controversial in reducing the risk of post PE complications.
PERT is a multidisciplinary group of clinicians who can rapidly assess and triage patients with acute PE, coordinate access to medical and advanced therapies, and provide the necessary follow up care.
Show Notes - Caring for the Middle Child of Pulmonary Embolism – Texas Heart Institute
How do you define “submassive” pulmonary embolism?
Venous thromboembolism, which includes deep vein thrombosis and acute pulmonary emboli (PE) are the third most common cardiovascular disorder in the United States with approximately 900,000 cases occurring each year (1). The morbidity and mortality associated with pulmonary emboli are also great, with approximately 33% of PE cases being fatal (1).Until recently, PE was previously classified into massive or non-massive. Massive PE was defined as those with cardiogenic shock. A newer group, “submassive PE”, was defined as an “intermediate” risk group. According to the American Heart Association (AHA) Scientific Statement on the management of massive and submassive PE, patients in this group presented with signs of RV dysfunction and myocardial necrosis without hemodynamic instability (2).
Intermediate-risk PE covers a broad range of risk and management decisions remain challenging. Intermediate-risk PE convers increased risk for mortality and complications compared with low-risk PE.
How do you risk-stratify intermediate-risk pulmonary emboli?
The AHA, American College of Chest Physicians (ACCP), and European Society of Cardiology (ESC) have variable definitions of submassive PE and which biomarkers should be used (1,3). The contents are summarized as below (Table 1)
Each major guideline highlights the importance of the evaluation of RV dysfunction (RVD) and elevated biomarkers. To summarize,
318. Cardio-Oncology: Training and Future Directions with Dr. Stephanie Feldman
Jul 17, 2023
CardioNerds cofounder Dr. Daniel Ambinder, series co-chair Dr. Dinu Balanescu (FIT, Mayo Clinic), and episode lead Dr. Anjali Rao (FIT, UTSW) discuss training in cardio-oncology with Dr. Stephanie Feldman from Rutgers University. In this episode, the group discusses some of the most burning questions about educating the next wave of cardio-oncologists. As Dr. Feldman mentions, the projected number of cancer survivors is predicted to be around 24 million by 2024, underscoring the growing importance of cardio-oncology in our practice. We highlight some of the challenges facing trainees and training programs alike, including how to integrate cardio-oncology education into general cardiology training, the optimal structure for an advanced cardio-oncology fellowship, and the role of cardio-oncology in the inpatient setting. We also talk about the takeaways from the ACC Cardio-Oncology Leadership Council document. Dr. Feldman reflects on the importance of flexibility in education in the current landscape, drawing on her personal experience as a cardio-oncologist during the COVID-19 era. Notes were drafted by Dr. Anjali Rao. Audio editing was performed by student doctor, Shivani Reddy.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Cardio-Oncology: Training and Future Directions
It may be possible to achieve “COCATS level 2” cardio-oncology training during general cardiology fellowship. A dedicated cardio-oncology year may appeal to trainees who want to achieve “COCATS level 3”, i.e., dedicate their practice to caring for patients with complex cardio-oncology needs, become involved in clinical trials, and lead cardio-oncology clinical and training programs.
Supplemental learning opportunities for general fellows can include:
Rotating in a cardio-oncology clinic, ideally attached to a National Cancer Institute-designated cancer center
Multi-modality cardiac imaging
Participating in cardio-oncology research
Some currently available educational opportunities include:The International Cardio-Oncology Society (ICOS) weekly webinarsThe American Society of Echocardiography (ASE) webinars on global longitudinal strainThe American Society of Nuclear Cardiology lecture series on cardiac amyloidosis
Cardio-oncology focused conferences, such as the American College of Cardiology’s (ACC) Advancing the Cardiovascular Care of the Oncology Patient and Memorial Sloan Kettering’s Cardio-Oncology Symposium.
Each institution may have different inpatient cardio-oncology needs depending on whether there is a stand-alone cancer hospital or another format. Examples of inpatient consults that may benefit from having a cardio-oncologist involved include:Cardiovascular risk assessment prior to bone marrow transplant or cancer related surgery in a patient with known coronary artery diseaseImmune checkpoint inhibitor myocarditisChemotherapy-related cardiac dysfunction
Management of systemic anticoagulation in a patient with high CHA2DS2-VASc and chemotherapy related thrombocytopenia.
Show notes - Cardio-Oncology: Training and Future Directions
The need for cardio-oncology experience is undeniable given the growing population of patients with cancer and cardiovascular disease, particularly given the number of anti-neoplastic therapies with potential cardiovascular side effects. There are several strategies for incorporating cardio-oncolo...
317. Guidelines: 2021 ESC Cardiovascular Prevention – Question #30 with Dr. Eugenia Gianos
Jul 14, 2023
The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by MGH internal medicine resident Dr. Christian Faaborg-Andersen, answered first by UCSD early career preventive cardiologist Dr. Harpreet Bhatia, and then by expert faculty Dr. Eugenia Gianos.
Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the Director of Women’s Heart Health at Lenox Hill Hospital and Director of Cardiovascular Prevention for Northwell Health.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #30
A 65-year-old woman with a history of hypertension, type 2 diabetes mellitus, and coronary artery disease with remote PCI to the RCA presents for follow-up. She has stable angina symptoms that are well controlled with metoprolol tartrate 25 mg BID and are not lifestyle limiting. She takes aspirin 81 mg daily and atorvastatin 40 mg daily. Her LDL-C is 70 mg/dL, hemoglobin A1c is 7.0%, and eGFR is >60. In clinic, her BP is 118/80 mmHg. What is the next step in management?AIncrease atorvastatin for goal LDL-C < 55 mg/dLBNo change in managementCAdd isosorbide mononitrate 30 mg dailyDStop aspirinEStart a sulfonylurea
Answer #30
Explanation The correct answer is A – increase atorvastatin for goal LDL-C < 55 mg/dL.In patients with established ASCVD, the ESC guidelines advocate for an LDL goal of < 55 mg/dL with at least a 50% reduction from baseline levels (Class I, LOE A). This patient has stable angina which is not lifestyle limiting; as such, further anti-anginal therapy is not necessary. She has known CAD with prior PCI, so aspirin therapy is appropriate for secondary prevention (Class I, LOE A). There is no indication for a sulfonylurea as her diabetes is well controlled. Notably, in persons with type 2 DM and ASCVD, the use of a GLP-1RA or SGLT2 inhibitor with proven outcome benefits is recommended to reduce CV and/or cardiorenal outcomes (Class I, LOE A).Main TakeawayFor people with established ASCVD, the ESC-recommended LDL-C goal is < 55 mg/dL with a goal reduction of at least 50%.Guideline Loc.Section 6.1
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316. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #24 with Dr. Ileana Pina
Jul 13, 2023
The following question refers to Sections 10.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy House Faculty Leader Dr. Dinu Balanescu, and then by expert faculty Dr. Ileana Pina.
Dr. Pina is Professor of Medicine and Quality Officer for the Cardiovascular Line at Thomas Jefferson University, Clinical Professor at Central Michigan University, and Adjunct Professor of Biostats and Epidemiology at Case Western University. She serves as Senior Fellow and Medical Officer at the Food and Drug Administration’s Center for Devices and Radiological Health.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #24
Mr. E. Regular is a 61-year-old man with a history of HFrEF due to non-ischemic cardiomyopathy (latest LVEF 40% after >3 months of optimized GDMT) and persistent atrial fibrillation. He has no other medical history. He has been on metoprolol and apixaban and has also undergone multiple electrical cardioversions and catheter ablations for atrial fibrillation but remains symptomatic with poorly controlled rates. His blood pressure is 105/65 mm Hg. HbA1c is 5.4%. Which of the following is a reasonable next step in the management of his atrial fibrillation?
A
Anti-arrhythmic drug therapy with amiodarone. Stop apixaban.
B
Repeat catheter ablation for atrial fibrillation. Stop apixaban.
C
AV nodal ablation and RV pacing. Shared decision-making regarding anticoagulation.
D
AV nodal ablation and CRT device. Shared decision-making regarding anticoagulation.
Answer #24
Explanation
The correct answer is D – AV nodal ablation and CRT device along with shared decision-making regarding anticoagulation.”
Maintaining sinus rhythm and atrial-ventricular synchrony is helpful in patients with heart failure given the hemodynamic benefits of atrial systole for diastolic filling and having a regularized rhythm.
Recent randomized controlled trials suggest that catheter-based rhythm control strategies are superior to rate control and chemical rhythm control strategies with regards to outcomes in atrial fibrillation. For patients with heart failure and symptoms caused by atrial fibrillation, ablation is reasonable to improve symptoms and quality of life (Class 2a, LOE B-R). However, Mr. Regular has already had multiple failed attempts at ablations (option B).
For patients with AF and LVEF ≤50%, if a rhythm control strategy fails or is not desired,
and ventricular rates remain rapid despite medical therapy, atrioventricular nodal ablation with implantation of a CRT device is reasonable (Class 2a, LOE B-R). The PAVE and BLOCK-HF trials suggested improved outcomes with CRT devices in these patients.
RV pacing following AV nodal ablation has also been shown to improve outcomes in patients with atrial fibrillation refractory to other rhythm control strategies. In patients with EF >50%, there is no evidence to suggest that CRT is more beneficial compared to RV-only pacing. However, RV pacing may produce ventricular dyssynchrony and when compared to CRT in those with reduced EF (≤ 50%),
315. Case Report: A Mystery Mass in the Heart – University of Chicago – Northshore University
Jul 12, 2023
In this episode, CardioNerds co-founder Amit Goyal joins Dr. Iva Minga, Dr. Kevin Lee, and Dr. Juan Pablo Salazar Adum from the University of Chicago - Northshore in Evanston, IL to discuss a case of primary cardiac diffuse large B-cell lymphoma. The ECPR for this episode is provided by Dr. Amit Pursnani (Advanced Cardiac Imaging, Fellowship program director, NorthShore University HealthSystem). Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig.
Case synopsis: A 77-year-old man with no significant medical history presents to the emergency department with progressive shortness of breath for 1 week. He reports an unintentional 15-pound weight loss in the prior month as well as constipation and abdominal/flank pain. On examination he was found to be tachycardic with a regular rhythm and further evaluation with a chest X-ray and chest CT scan demonstrated a large pericardial effusion. This was further investigated with an urgent echocardiogram that revealed a large pericardial effusion with a large mass attached to the pericardial side of the RV free wall, as well as signs of early cardiac tamponade. A pericardiocentesis was performed and 550mL of bloody fluid was withdrawn. The fluid was sent for laboratory analysis and cytology. A cardiac MRI demonstrated a large invasive mass in the pericardium and RV wall consistent with cardiac lymphoma. Cytology confirmed diffuse large B-cell lymphoma. Subsequent CT and PET scans did not find any other site of malignancy, giving the patient a diagnosis of primary cardiac diffuse large B-cell lymphoma. The patient underwent R-CHOP chemotherapy and was followed closely with repeat cardiac MRI and PET scans which demonstrated resolution of the cardiac mass at his one-year surveillance follow-up.
This case was published in US Cardiology Review, the official journal of CardioNerds. To learn more, access the case report article here.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Pearls - A Mystery Mass in the Heart - Cardiac Lymphoma
The most common cause of malignant cardiac masses is metastasis.
Primary cardiac tumors are rare.
Cardiac tumors are separated into 2 categories: benign and malignant. They are often differentiated based on their location and their degree of tissue invasion.
Multimodality imaging is essential in the diagnosis, management, and surveillance of cardiac masses.
A multidisciplinary team approach is invaluable for management of patients with cardiac tumors.
Show Notes - A Mystery Mass in the Heart - Cardiac Lymphoma
1. What is the clinical presentation of cardiac masses?
Cardiac masses can have a variable presentation. They can present with arrhythmias, angina, heart failure symptoms, or pericardial effusion. Patients can also be asymptomatic; the masses can be found incidentally on cardiac or chest imagining.
2. What is the differential diagnosis for cardiac masses?
Cardiac masses are separated into benign and malignant. The most common malignant cardiac masses are metastases from a distant source. The location of the mass is important in narrowing the differential.
3. What imaging modalities are used to diagnose cardiac masses?
Multimodality imaging is needed to describe the mass in detail and guide diagnosis. An echocardiogram is usually the first imaging modality. Cardiac MRI is a great modality that allows for the...
314. Mastering the Art of Patient Care with Dr. Michelle Kittleson and the CardioNerds Interns
Jul 11, 2023
In this episode, Dr. Gurleen Kaur (medicine resident at Brigham and Women’s Hospital and Director of CardioNerds Internship) and CardioNerds Academy interns Dr. Akiva Rosenzveig (medicine intern at Cleveland Clinic), Dr. Chelsea Tweneboah (medicine intern at Stonybrook University), student doctor Shivani Reddy (medical student at Western Michigan University), student doctor Diane Masket (medical student at Rowan School of Osteopathic Medicine), and student doctor Tina Reddy (medical student at Tulane University School of Medicine) discuss with Dr. Michelle Kittleson (Director of Education in Heart Failure and Transplantation, Director of HF Research, and Professor of Medicine at Cedars Sinai) about Mastering the Art of Patient Care. Dr. Kittleson shares pearls of wisdom from her book on topics including career transitions, mentorship, dealing with uncertainty, learning from mistakes, delivering difficult news, and being a woman and parent in medicine.
This episode was planned by Dr. Gurleen Kaur and episode audio was edited by student doctor Tina Reddy.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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313. Stimulant-Associated Cardiomyopathy with Dr. Soraya Azari and Dr. Jonathan Davis
Jul 09, 2023
Dr. Amit Goyal (CardioNerds co-founder), Dr. Jessie Holtzman (House Faculty in CardioNerds Academy and cardiology fellow at UCSF), and Dr. Megan McLaughlin (CardioNerds Scholar and cardiology fellow at UCSF) discuss stimulant-associated cardiomyopathy with Dr. Jonathan Davis (Associate Professor at UCSF the Director of the Heart Failure Program at Zuckerberg San Francisco General Hospital) and Dr. Soraya Azari (Associate Clinical professor at UCSF, with specialty in hospital medicine, primary care, HIV medicine, and addiction medicine).
Methamphetamine-associated heart failure admissions have steadily increased in the United States over the past decade. Substance use disorders more broadly are thought to complicate at least 15% of all heart failure hospitalizations and amphetamine use has been shown to be an independent predictor of heart failure readmission across the country. At safety net and public hospitals, these numbers may rise even higher. This episode reviews the pathophysiology of stimulant associated cardiomyopathy, highlights treatment options for stimulant use disorder, and discusses novel models of co-management of heart failure and substance use disorder.
Notes were drafted by Dr. Jessie Holtzman. Audio editing by CardioNerds academy intern, Pace Wetstein.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Pearls - Stimulant-Associated Cardiomyopathy
Though there are no pathognomonic traits of stimulant-associated cardiomyopathy, common echocardiographic features include biventricular dilated cardiomyopathy and/or pulmonary hypertension with a dilated, hypokinetic right ventricle and underfilled left ventricle. Enjoy CardioNerds Episode 312. Case Report: Life in the Fast Lane Leads to a Cardiac Conundrum to learn from a case of stimulant associated pulmonary arterial hypertension.
Not all cardiomyopathy in patients who use stimulants is due to stimulant use. Do your due diligence. Patients who use stimulants should undergo a broad work-up to diagnose the etiology of cardiomyopathy.
Tips for taking a substance use history:
Ask permission to discuss the topic.
Normalize the behavior.
Use specific drug names (also, learn the local drug nicknames!).
Ask about any history of prior treatment and periods of abstinence.
Screen for risk of harm or overdose
Try using a phrase like “I’m asking you this because I want to know if the way you are using drugs can impact your health and keep you safe.”
There are no FDA-approved medications to treat stimulant use disorder. Common off-label therapies include mirtazapine and bupropion/naltrexone.
Contingency management programs work off the principle of operant conditioning; they reward patients for maintaining abstinence from substance use.
For clinicians to seek assistance in providing treatment for stimulant use disorder, important resources include:
SAMSA (national help line 1-800-662-HELP or online resource locator)
HarmReduction.Org
Never Use Alone hotline (800-484-3731)
Show notes - Stimulant-Associated Cardiomyopathy
1. What are common clinical presentations of stimulant-associated cardiomyopathy?
Stimulants have multifactorial physiologic impacts, due both to pharmacologic properties (adrenergic stimulation and vasoconstriction) and direct toxic effects. Clinical manifestations may include hypertension, tachyarrhythmias, acute myocardial infarction, cardiomyopathy, pulmonary hypertension, aortic dissection, and sudden cardiac death.
On echocardiogram, stimulant-associated cardiomyopathy may manifest as biventricular dilated cardiomyopathy,
312. Case Report: Life in the Fast Lane Leads to a Cardiac Conundrum – Los Angeles County + University of Southern California
Jun 23, 2023
CardioNerds (Drs. Amit Goyal and Dan Ambinder) join Dr. Emily Lee (LAC+USC Internal medicine resident) and Dr. Charlie Lin (LAC+USC Cardiology fellow) as the discuss an important case of stimulant-related (methamphetamine) cardiovascular toxicity that manifested in right ventricular dysfunction due to severe pulmonary hypertension. Dr. Jonathan Davis (Director, Heart Failure Program at Zuckerberg San Francisco General Hospital and Trauma Center) provides the ECPR for this episide. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
With the ongoing methamphetamine epidemic, the incidence of stimulant-related cardiovascular toxicity continues to grow. We discuss the following case: A 36-year-old man was hospitalized for evaluation of dyspnea and volume overload in the setting of previously untreated, provoked deep venous thrombosis. Transthoracic echocardiogram revealed severe right ventricular dysfunction as well as signs of pressure and volume overload. Computed tomography demonstrated a prominent main pulmonary artery and ruled out pulmonary embolism. Right heart catheterization confirmed the presence of pre-capillary pulmonary arterial hypertension without demonstrable vasoreactivity. He was prescribed sildenafil to begin management of methamphetamine-associated cardiomyopathy and right ventricular dysfunction manifesting as severe pre-capillary pulmonary hypertension.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Media - stimulant-related (methamphetamine) cardiovascular toxicity
Pearls - stimulant-related (methamphetamine) cardiovascular toxicity
1. Methamphetamine, and stimulants in general, can have a multitude of effects on the cardiovascular and pulmonary systems. Effects of methamphetamine are thought to be due to catecholamine toxicity with direct effects on cardiac and vascular tissues. Acutely, methamphetamine can cause vascular constriction and vasospasm, while chronic exposure is associated with endothelial damage. Over time, methamphetamine can cause pulmonary hypertension, atherosclerosis, cardiac arrhythmias, and dilated cardiomyopathy.
2. Methamphetamines are the second most commonly misused substances worldwide after opiates. Patients with methamphetamine-associated pulmonary arterial hypertension (PAH) have more severe pulmonary vascular disease, more dilated and dysfunctional right ventricles, and worse prognoses when compared to patients with idiopathic PAH. Additionally, patients with methamphetamine-associated cardiomyopathy and PAH have significantly worse outcomes and prognoses when compared to those with structurally normal hearts without evidence of PAH. Management includes multidisciplinary support, complete cessation of methamphetamine use, and guideline-directed treatment of PAH.
3. The diagnosis of pulmonary hypertension (PH) begins with the history and physical, followed by confirmatory testing using echocardiography and invasive hemodynamics (right heart catheterization). Initial serological evaluation may include routine biochemical, hematologic, endocrine, hepatic, and infectious testing. Though PH is traditionally diagnosed and confirmed in a two-step, echocardiogram-followed-by-catheterization model, other diagnostics often include electrocardiography, blood gas analysis, spirometry, ventilation/perfusion assessment,
311. Guidelines: 2021 ESC Cardiovascular Prevention – Question #29 with Dr. Laurence Sperling
Jun 22, 2023
The following question refers to Section 5.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by MGH medicine resident Dr. Christian Faaborg-Andersen, answered first by Dr. Jessie Holtzman, and then by expert faculty Dr. Laurence Sperling.Dr. Laurence Sperling is the Katz Professor in Preventive Cardiology at the Emory University School of Medicine and Founder of Preventive Cardiology at the Emory Clinic. Dr. Sperling was a member of the writing group for the 2018 Cholesterol Guidelines, serves as Co-Chair for the ACC's Cardiometabolic and Diabetes working group, and is Co-Chair of the WHF Roadmap for Cardiovascular Prevention in Diabetes.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #29
What percentage of the European population currently meets the recommended physical activity guidelines (150 minutes moderate-intensity activity weekly or 75 minutes vigorous-intensity activity weekly)?A<10%B10-25%C25-50%D50-75%E>75%
Answer #29
ExplanationThe correct answer is A: <10% of the European population currently meets the recommended physical activity guidelines.The American Heart Association, European Society of Cardiology, and World Health Organization all share the recommendation that adults should engage in 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity activity. They recognize that additional health benefits may be garnered from incremental increases to 300 minutes per week of moderate intensity activity or 150 minutes per week of vigorous intensity activity, with a recommendation to include both aerobic and muscular strength training activities.According to the WHO, physical inactivity is the 4th leading cause of death in the world. The statistics regarding physical inactivity are staggering. Recent studies have shown that <10% of the European population meets the minimum recommended levels of physical activity. Similarly, ¼ adults and ¾ adolescents (aged 11-17) do not currently meet the global recommendations for physical activity. The World Health Organization has created a Global Action Plan on Physical Activity 2018-2030 with the goal to achieve a 15% relative reduction in the global prevalence of physical inactivity by 2030.Society level interventions to increase physical activity have been proposed including school-based activity programs, improved accessibility of exercise facilities across the socioeconomic spectrum, and governmental consideration of physical activity when designing cities (i.e. including pedestrian and cycling lanes). Other policy suggestions with varying levels of evidence include focused media campaigns, economic incentives, targeting labeling of physical activity opportunities, and work-place wellness programs.Main TakeawayDespite growing awareness of the health consequences of sedentary behavior, fewer than 10% of adults currently meet the minimum recommended quantity of physical activity. Public health leaders may continue to consider novel legislative initiatives to augment physical activity on a societal level with architectural design and financial incentives.Guideline Loc.Section 5.2
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310. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #23 with Dr. Anu Lala
Jun 19, 2023
The following question refers to Section 9.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Cedars Sinai medicine resident, soon to be Vanderbilt Cardiology Fellow, and CardioNerds Academy Faculty Dr. Breanna Hansen, and then by expert faculty Dr. Anu Lala.Dr. Lala is an advanced heart failure and transplant cardiologist, associate professor of medicine and population health science and policy, Director of Heart Failure Research, and Program Director for the Advanced Heart Failure and Transplant fellowship training program at Mount Sinai. Dr. Lala is Deputy Editor for the Journal of Cardiac Failure. Dr. Lala has been a champion and role model for CardioNerds. She has been a PI mentor for the CardioNerds Clinical Trials Network and continues to serve in the program’s leadership. She is also a faculty mentor for this very 2022 heart failure decipher the guidelines series.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #23
Mrs. Hart is a 63-year-old woman with a history of non-ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 20-25%) presenting with 5 days of worsening dyspnea and orthopnea.
At home, she takes carvedilol 12.5mg BID, sacubitril-valsartan 24-46mg BID, empagliflozin 10mg daily, and furosemide 40mg daily.
On admission, her exam revealed a blood pressure of 111/79 mmHg, HR 80 bpm, and SpO2 94%. Her cardiovascular exam was significant for a regular rate and rhythm with an audible S3, JVD to 13 cm H2O, bilateral lower extremity pitting edema with warm extremities and 2+ pulses throughout. What initial dose of diuretics would you give her?
A
Continue home Furosemide 40 mg PO
B
Start Metolazone 5 mg PO
C
Start Lasix 100 mg IV
D
Start Spironolactone
Answer #23
Explanation
The correct answer is C – start Furosemide 100 mg IV.
This is the most appropriate choice because patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to improve symptoms and reduce morbidity (Class 1, LOE B-NR). Intravenous loop diuretic therapy provides the most rapid and effective treatment for signs and symptoms of congestion. Titration of diuretics has been described in multiple recent trials of patients hospitalized with HF,
often initiated with at least 2 times the daily home diuretic dose (mg to mg) administered intravenously. Titration to achieve effective diuresis may require doubling of initial doses, adding a thiazide diuretic, or adding an MRA that has diuretic effects in addition to its cardiovascular benefits.
Choice A is incorrect as continuing oral loop diuretics is not recommended for acute decongestion. Moreover, Ms. Hart has become congested despite her home, oral diuretic regimen.
Choice B and D are incorrect as starting a thiazide diuretic or a mineralocorticoid receptor antagonist are not first-line therapy for acute HF. Rather, in patients hospitalized with HF when diuresis is inadequate to relieve symptoms and signs of congestion, it is reasonable to intensify the diuretic regimen using either: a.
309. Atrial Fibrillation: Situational Assessment of Stroke and Bleeding Risk with Dr. Hafiza Khan
Jun 18, 2023
Dr. Daniel Ambinder (CardioNerds Co-Founder), Dr. Kelly Arps (Series Co-Chair and EP fellow at Duke University), Dr. Stephanie Fuentes Rojas (FIT Lead and EP fellow at Houston Methodist), and Dr. Ingrid Hsiung (Cardiology Fellow at Baylor Scott & White Health) discuss situational assessment of stroke and bleeding risk with expert faculty Dr. Hafiza Khan (Electrophysiologist at Baylor Scott & White Health). In this episode, we discuss stroke and bleeding risk in specific situations such as prior to cardioversion, triggered episodes, and perioperatively. These are scenarios that are commonly encountered and pose specific challenges. Episode notes were drafted by Dr. Stephanie Fuentes. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This series is supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
We have collaborated with VCU Health to provide CME. Claim free CME here!
Disclosures: Dr. Ellis discloses grant or research support from Boston Scientific, Abbott-St Jude, advisor for Atricure and Medtronic.
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Pearls and Quotes - Atrial Fibrillation: Situational Assessment of Stroke and Bleeding Risk
In patients with persistent atrial fibrillation with tachycardia induced cardiomyopathy, timely restoration of normal rhythm is important. In patients not on established oral anticoagulation one option is to wait 3 weeks on oral anticoagulation prior to considering cardioversion. Another option is to pursue TEE prior to cardioversion as TEE is currently the gold standard imaging modality to exclude a LAA thrombus.
Following cardioversion (chemical or electrical), anticoagulation must not be interrupted for 4 weeks due to atrial stunning. This is especially true for patients who have been in atrial fibrillation for an extended period of time.
Individualizing assessment of stroke and bleeding risk is imperative when determining perioperative anticoagulation (AC) management. ACC has a helpful app (ManageAnticoag App) to make this easier.
When considering AC in triggered atrial fibrillation (e.g., pneumonia, sepsis), it is important to consider the substrate that made the patient susceptible to developing atrial fibrillation. AC is favored in patients with high CHA2DS2-VAsC score and many traditional risk factors for atrial fibrillation as they are at high risk for future development of atrial fibrillation.
Atrial fibrillation is a marker of poor outcomes in patients who have undergone coronary artery bypass graft (CABG) surgery. It is unclear if patients should be started on long-term AC for new onset atrial fibrillation after CABG regardless of risk factors. This is currently being investigated in the PACES trial.
Notes - Atrial Fibrillation: Situational Assessment of Stroke and Bleeding Risk
How do we choose an imaging modality for excluding LAA thrombus exclusion prior to cardioversion?
TEE is the gold standard. It also provides other information that is important for management of atrial fibrillation (e.g. LA size/volume, presence/degree of mitral regurgitation/stenosis, ejection fraction).
Gated cardiac CTA may have a growing role for evaluation of LAA thrombus.
What is the data behind the recommendation for uninterrupted AC following cardioversion and what is atrial stunning?
All patients should be anticoagulated for four weeks after cardioversion,
308. Guidelines: 2021 ESC Cardiovascular Prevention – Question #28 with Dr. Roger Blumenthal
Jun 12, 2023
The following question refers to Section 4.7 and Table 18 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Student Dr. Shivani Reddy, answered first by Fellow at Johns Hopkins Dr. Rick Ferraro, and then by expert faculty Dr. Roger Blumenthal.Dr. Roger Blumenthal is professor of medicine at Johns Hopkins where he is Director of the Ciccarone Center for the Prevention of Cardiovascular Disease. He was instrumental in developing the 2018 ACC/AHA CV Prevention Guidelines. Dr. Blumenthal has also been an incredible mentor to CardioNerds from our earliest days.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #28
Mr. A. C. is a 78-year-old gentleman with a long-standing history of HTN receiving antihypertensive medications & dietary management for blood pressure control. What is the target diastolic blood pressure recommendation for all treated patients such as Mr. A.C.?A< 80 mmHgB< 90 mmHgC< 70 mmHgD< 95 mmHgE< 100 mmHg
Answer #28
Explanation
The correct answer is A: DBP < 80 mmHg
Blood pressure treatment targets: when drug treatment is used, the aim is to control BP to target within 3 months. Blood pressure treatment targets in the 2021 ESC Prevention guidelines are more aggressive than previously recommended, as evidence now suggests the previously recommended targets were too conservative, especially for older patients.
The magnitude of BP lowering is the most important driver of benefit.
· It is recommended that the first objective of treatment is to lower BP to <140/90 mmHg in all patients, and that subsequent BP targets are tailored to age and specific comorbidities (Class 1).
· In treated patients aged 18-69 years, it is recommended that SBP should ultimately be lowered to a target range of 120 – 130 mmHg in most patients (Class 1).
· In treated patients aged ≥70 years, it is recommended that SBP should generally be targeted to <140 and down to 130 mmHg if tolerated (Class 1).
· In all treated patients, DBP is recommended to be lowered to <80 mmHg (Class I).
This change in the BP target range for older people compared with the 2016 ESC prevention guidelines is supported by evidence that these treatment targets are safely achieved in many older patients and are associated with significant reductions in the risk of major stroke, HF, and CV death. It also takes into account that the even lower SBP in the intensively treated group in SPRINT (Systolic Blood Pressure Intervention Trial) (mean 124 mmHg) probably reflects a conventional office SBP range of 130-139 mmHg. It is recognized, however, that the evidence supporting more strict targets is less strong for very old people (>80 years) and those who are frail. Also, in these older and especially frail patients, it may be difficult to achieve the recommended target BP range due to poor tolerability or adverse effects, and high-quality measurement and monitoring for tolerability and adverse effects is especially important in these groups.
Main Takeaway
The first step in HTN management in all groups is a reduction to SBP < 140 mmHg and DBP < 80 mmHg, with further targets depending on age and comorbidities as specified by Table 18 of the 2021 ESC Prevention Guidelines.
Guideline Loc.
1. 4.7.5.3 page 3285
2. Table 18 page 3287
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307. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #22 with Dr. Prateeti Khazanie
Jun 09, 2023
The following question refers to Section 8.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by University of Southern California cardiology fellow and CardioNerds FIT Trialist Dr. Michael Francke, and then by expert faculty Dr. Prateeti Khazanie.
Dr. Khazanie is an associate professor and advanced heart failure and transplant Cardiologist at the University of Colorado. Dr. Khazanie is an author on the 2022 ACC/AHA/HFSA HF Guidelines, the 2021 HFSA Universal Definition of Heart Failure, and multiple scientific statements.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Clinical Trials Talks
Question #22
You are taking care of a 34-year-old man with chronic systolic heart failure from NICM with LVEF 20% s/p CRT-D. The patient was admitted 1 week prior with acute decompensated heart failure. Despite intravenous diuretics the patient developed acute kidney injury, and ultimately placed on intravenous inotropes on which he now seems dependent. He has been following up with an advanced heart failure specialist as an outpatient and has been undergoing evaluation for heart transplantation, which was subsequently completed in the hospital.
His exam is notable for an elevated JVP, a III/VI holosystolic murmur, and warm extremities with bilateral 1+ edema. His most recent TTE shows LVEF 20%, moderate MR, moderate-severe TR and estimated RVSP 34 mmHg. His most recent laboratory data shows Na 131 mmol/L, Cr 1.2 mg/dL, and lactate 1.6 mmol/L. Pulmonary artery catheter shows RA 7 mmHg, PA 36/15 mmHg, PCWP 12 mmHg, CI 2.4 L/min/m2 and SVR 1150 dynes*sec/cm5.
The patient was presented at transplant selection committee and approved for listing for orthotopic heart transplant. What is the most appropriate next step in the management of this patient?
A
Refer patient for transcatheter edge-to-edge repair for MR
B
Continue IV inotropes as a bridge-to-transplant
C
Refer patient for tricuspid valve replacement
D
Initiate 1.5L fluid restriction
Answer #22
Explanation
The correct answer is B – continue IV inotropes as a bridge-to-transplant.
Positive inotropic agents may improve hemodynamic status, but have not been shown to improve survival in patients with HF. These agents may help HF patients who are refractory to other therapies and are suffering consequences from end-organ-hypoperfusion.
Our patient is admitted with worsening advanced heart failure requiring intravenous inotropic support. He has been appropriately evaluated and approved for heart transplant. He has demonstrated the requirement of continuous inotropic support to maintain perfusion. In patients such as this with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as “bridge therapy” (Class 2a, LOE B-NR).
Continuous IV inotropes also have a Class 2b indication (LOE B-NR) in select patients with stage D HF despite optimal GDMT and device therapy who are ineligible for either MCS or cardiac transplantation, as palliative therapy for symptom control and improvement in functio...
306. Decompensated Right Ventricular Failure in Pulmonary Arterial Hypertension with Dr. Mardi Gomberg-Maitland and Dr. Rachel Damico
Jun 08, 2023
The CardioNerds and Pulm PEEPs have joined forces to co-produce this important episode, delving into the management of decompensated right ventricular failure in pulmonary arterial hypertension. Joining us for this informative discussion are Pulm PEEPs co-founders, Dr. David Furfaro and Dr. Kristina Montemayor, along with Dr. Leonid Mirson (Internal Medicine Resident at Johns Hopkins Osler Medical Residency and Associate Editor of Pulm PEEPs), Dr. Bavya Varma (Internal Medicine Resident at Johns Hopkins, rising Cardiology Fellow at NYU, and CardioNerds Academy graduate), Dr. Mardi Gomberg-Maitland (Medical Director of the Pulmonary Hypertension Program at George Washington Hospital), and Dr. Rachel Damico (Pulmonologist and Associate Professor of Medicine at Johns Hopkins Hospital). Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Show notes - Decompensated Right Ventricular Failure in Pulmonary Arterial Hypertension
A 21-year-old woman with a past medical history notable for congenital heart disease (primum ASD and sinus venosus with multiple surgeries) complicated by severe PAH on home oxygen, sildenafil, ambrisentan, and subcutaneous treprostinil is presenting with palpitations, chest pain, and syncope. She presented as a transfer from an outside ED where she arrived in an unknown tachyarrhythmia and had undergone DCCV due to tachycardia into the 200s and hypotension. On arrival at our hospital, she denied SOB but did endorse nausea, leg swelling, and poor medication adherence. Her initial vitals were notable for a BP of 80/50, HR 110, RR 25, and saturating 91% on 5L O2. On exam, she was uncomfortable appearing but mentating well. She had cool extremities with 1-2+ LE edema. Her JVP was 15cm H2O. She has an RV Heave and 2/6 systolic murmur. Her lungs were clear bilaterally. Her labs were notable for Cr 2.0, an anion gap metabolic acidosis (HCO3 = 11), elevated lactate (4.1), elevated troponin to 14, and a pro-BNP of ~5000. Her CBC was unremarkable. Her EKG demonstrated 2:1 atrial flutter at a rate of 130.
Diagnosing RV failure in patients with PH:
RV dysfunction and RV failure are two separate entities. RV dysfunction can be measured on echocardiography, but RV failure can be thought of as a clinical syndrome where there is evidence of RV dysfunction and elevated right sided filling pressures.
RV failure is a spectrum and can present with a range of manifestations from evidence of R sided volume overload and markers of organ dysfunction, all the way to frank cardiogenic shock. Most patients with RV failure are not in overt shock.
One of the first signs of impending shock in patients with RV failure is the development of new or worsening hypoxemia. Patients with decompensated RV failure approaching shock often do not present with symptoms classic for LV low flow state. Instead, hypoxia 2/2 VQ mismatching may be the first sign and they can be otherwise well appearing. Particularly because patients with PH tend to be younger, they can often appear compensated until they rapidly decompensate.
Causes of decompensation for patients with RV dysfunction and PH:
Iatrogenesis (inadvertent cessation of pulmonary vasodilators by providers, surgery if providers are not familiar with risks of anesthesia), non-adherence to pulmonary vasodilators (either due to affordability issues or other reasons), infections, arrhythmias (particularly atrial arrhythmias), and progression of underlying disease.
Patients with atrial arrhythmias (atrial flutter or atrial fibrillation) and pulmonary hypertension do not tolerate the loss of...
305. Guidelines: 2021 ESC Cardiovascular Prevention – Question #27 with Dr. Kim Williams
Jun 06, 2023
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by medicine resident CardioNerds Academy House Chief Dr. Ahmed Ghoneem, and then by expert faculty Dr. Kim Williams.Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016).
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #27
Mr. O is a 48-year-old man with a past medical history significant for obesity (BMI is 42kg/m2), hypertension, type 2 diabetes mellitus, and hypercholesterolemia. His calculated ASCVD risk score today is 18.8%. You counsel him on the importance of weight loss in the context of CVD risk reduction. Which of the following weight loss recommendations is appropriate?AMaintaining a weight loss of at least 25% from baseline is required to influence blood pressure, cholesterol, and glycemic control. BHypocaloric diets lead to short term weight loss, but a healthy diet should be maintained over time to reduce CVD risk.CLiraglutide can be used to induce weight loss, as an alternative to diet and exercise.DBariatric surgery is effective for weight loss but has no ASCVD risk reduction benefit.
Answer #27
Explanation
The correct answer is B. Energy restriction is the cornerstone of management of obesity. All the different types of hypocaloric diets achieve similar short-term weight loss, but these effects tend to diminish by 12 months. It is a class I recommendation to maintain a healthy diet over time to achieve CVD risk reduction. The Mediterranean diet is an example of a diet that can have persistent CV benefit beyond the 12 months.
Choice A is incorrect because maintaining even a moderate weight loss of 5 – 10% from baseline has favorable effects on risk factors including blood pressure, cholesterol, and glycemic control, as well as on premature all-cause mortality.
Choice C is incorrect because medications approved as aids to weight loss (such as liraglutide, orlistat and naltrexone/bupropion) may be used in addition to lifestyle measures to achieve weight loss and maintenance; they are not alternatives to a healthy lifestyle. Meta-analysis of medication-assisted weight loss found favorable effects on BP, glycemic control, and ASCVD mortality.
Choice D is incorrect because patients undergoing bariatric surgery had over 50% lower risks of total ASCVD and cancer mortality compared with people of similar weight who did not have surgery. Bariatric surgery should be considered for obese high-risk individuals when lifestyle change does not result in maintained weight loss (Class IIa). The ACC/AHA guidelines focused primarily on lifestyle interventions for obesity and had no specific recommendations for bariatric surgery or medication-assisted weight loss.
Main Takeaway
Weight reduction (even as low as 5-10% from baseline) and long-term maintenance of a healthy diet are recommended to improve the CVD risk profile of overweight and obese people. Medication and/or bariatric surgery may have a useful adjunctive role in some patients.
Guideline Loc.
Section 4.3.3
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304. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #21 with Dr. Nancy Sweitzer
May 31, 2023
The following question refers to Section 7.6 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by premedical student and CardioNerds Intern Pacey Wetstein, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy Chief Dr. Teodora Donisan, and then by expert faculty Dr. Nancy Sweitzer.Dr. Sweitzer is Professor of Medicine, Vice Chair of Clinical Research for the Department of Medicine, and Director of Clinical Research for the Division of Cardiology at Washington University School of Medicine. She is the editor-in-chief of Circulation: Heart Failure. Dr. Sweitzer is a faculty mentor for this Decipher the HF Guidelines series.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Clinical Trials Talks
Question #21
Ms. Smith is a 56-year-old woman following up in the cardiology clinic for a history of heart failure with reduced ejection fraction. Two years ago, she was diagnosed with non-ischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 30%. Over time, she was initiated and optimized on guideline directed medical therapy. She is currently on Carvedilol 12.5 mg BID, Sacubitril/Valsartan 49/51 mg BID, Spironolactone 25 mg daily, Empagliflozin 10 mg daily, and Furosemide PRN for weight gain.
On today’s visit, her BP is 110/80 mmHg, and her HR is 67 bpm. Labs show a creatinine of 0.9 mg/dL, potassium of 5.1 mEq/L, NT-proBNP of 150 ng/L, and a HbA1c of 5.8%. Follow up transthoracic echocardiogram showed an improvement in LVEF to 55%. What are the most appropriate therapy recommendations for Ms. Smith?
A
Discontinue spironolactone
B
Discontinue empagliflozin
C
Decrease the dose of carvedilol
D
Continue current therapy
Answer #21
The correct answer is D – continue current therapy.
The patient described above was initially diagnosed with HFrEF and experienced significant symptomatic improvement with GDMT, so she now has heart failure with improved ejection fraction (HFimpEF). In patients with HFimpEF after treatment, GDMT should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic (Class 1, LOE B-R). Although symptoms, functional capacity, LVEF and reverse remodeling can improve with GDMT, structural abnormalities of the LV and its function do not fully normalize, causing symptoms and biomarker changes to persist or recur if treatment is deescalated. Improvements in EF do not always reflect sustained recovery; rather, they signify remission.
Of note, HF relapse can be defined by at least 1 of the following:
o A drop in the EF by >10% and to < 50%
o An increase in LVEDV by >10% and to higher than the normal range
o A 2-fold rise in NT-proBNP concentration and to > 400 ng/L
o Clinical evidence of HF on examination
Choice A is incorrect as it would be incorrect to discontinue spironolactone. A potassium of 5.1 is still within the acceptable limit in a patient who has been on Spironolactone for two years, and this medication is an important part of GDMT for HFrEF.
Despite the improvement in Hb A1c, empagliflozin should be continued for heart failure with improved ejection fraction, as it is part of routine GDMT of HFrEF even in the absence of diabetes.
303. CCC: Management of Ventricular Tachycardia and Electrical Storm in the CICU with Dr. Janice Chyou
May 29, 2023
CardioNerds Co-Founder, Dr. Amit Goyal, along with Series Co-Chairs, Dr. Yoav Karpenshif and Dr. Eunice Dugan, and episode Lead, Dr. Sean Dikdan, had the opportunity to expand their knowledge on the topic of ventricular tachycardia and electrical storm from esteemed faculty expert, Dr. Janice Chyou. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
Electrical storm (ES) is a life-threatening arrhythmia syndrome. It is characterized by frequently occurring bouts of unstable cardiac arrythmias. It typically occurs in patients with susceptible substrate, either myocardial scar or a genetic predisposition. The adrenergic input of the sympathetic nervous system can perpetuate arrythmia. In the acute setting, identifying reversible triggers, such as ischemia, electrolyte imbalances, and heart failure, is important. Treatment is complex and varies based on previous treatments received and the presence of intra-cardiac devices. Many options are available to treat ES, including medications, intubation and sedation, procedures and surgeries targeting the autonomic nervous system, and catheter ablation to modulate the myocardial substrate. A multidisciplinary team of cardiologists, intensivists, electrophysiologists, surgeons, and more are necessary to manage this complex disease.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Management of Ventricular Tachycardia and Electrical Storm
Electrical storm is defined as 3 or more episodes of VF, sustained VT, or appropriate ICD shocks within 24 hours. It occurs more commonly in ischemic compared to non-ischemic cardiomyopathy, and it is associated with a poor prognosis and high cardiovascular mortality.
The classic triad of electrical storm is a trigger, a myocardial susceptible substrate, and autonomic input perpetuating the storm.
Triggers for electrical storm include ischemia, heart failure, electrolyte abnormalities, hypoxia, drug-related arrhythmogenicity, and thyrotoxicosis. A thorough evaluation of possible triggers is necessary for each patient, but it is uncommonly found. The evaluation may include laboratory studies, genetic testing, advanced imaging, or invasive testing.
Acute treatment options involve acute resuscitation, pharmacotherapy with antiarrhythmics and beta-blockers, device interrogation and possible reprogramming, and sedation. Subacute treatment involves autonomic modulation and catheter ablation. Surgical treatments include sympathectomies and, ultimately, heart transplant.
Catheter ablation is safe and effective for the treatment of electrical storm. In select patients, hemodynamic peri-procedural hemodynamic support should be considered.
Show notes - Management of Ventricular Tachycardia and Electrical Storm
Simple diagram of the classic “triad” of ES (see reference 10).
Treatment algorithm provided by the 2017 AHA/ACC/HRS guidelines (see reference 1).
1. Define electrical storm.
Electrical storm (ES), also called “arrhythmic storm” or “VT storm” refers to a state of cardiac instability associated with 3 or more episodes of VF, sustained VT, or appropriate ICD shocks within 24 hours. Sustained VT refers to 30 seconds of VT or hemodynamically unstable VT requiring termination in < 30 seconds. Incessant VT refers to continued, sustained hemodynamically stable VT that lasts longer than one hour. VT is incessant or recurrent when it recurs promptly despi...
302. Guidelines: 2021 ESC Cardiovascular Prevention – Question #26 with Dr. Allison Bailey
May 28, 2023
The following question refers to Sections 3.3 and 3.4 of the 2021 ESC CV Prevention Guidelines.
The question is asked by CardioNerds Academy Intern student Dr. Adriana Mares, answered first by Brigham & Women’s medicine resident & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Allison Bailey.
Dr. Bailey is an advanced heart failure and transplant cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology’s Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #26
Ms. Priya Clampsia is a 58-year-old never-smoker with a history of hypertension. Her BMI is 29 kg/m2. She also mentions having pre-eclampsia during her pregnancy many years ago. She describes a predominately sedentary lifestyle and works as a receptionist. You see her in the clinic to discuss routine preventive care. Her most recent lipid panel results were LDL of 101 mg/dL, HDL of 45 mg/dL, and triglycerides of 190 mg/dL. What additional step will provide valuable information regarding her CVD risk profile?
A
Send additional lab workup including C-reactive protein and lipoprotein (a)
B
Measure her waist circumference
C
Assess her work stress
D
Ask her about history of preterm birth
E
B, C, and D
Answer #26
Explanation
The correct answer is E – measuring her waist circumference, assessing her occupational stress, and obtaining history about adverse pregnancy outcomes including preterm birth all add valuable information for CVD risk stratification.
BMI is easily measured and can be used to define categories of body weight. However, body fat stores in visceral tissue carry higher risk than subcutaneous fat and therefore, waist circumference can be a simple way to measure global and abdominal fat. When waist circumference is ≥102 cm in men and ≥88 cm in women, weight reduction is advised. While these WHO thresholds are widely accepted in Europe, it is important to note that different cut-offs may be appropriate in different ethnic groups.
Work stress is important to ascertain as well because there is preliminary evidence of the detrimental impact of worse stress on ASCVD health, independent of conventional risk factors and their treatment. Work stress is determined by job strain (i.e., the combination of high demands and low control at work) and effort-reward imbalance.
Pre-eclampsia is associated with increase in CVD risk by factor of 1.5-2.7 compared with all women. Both preterm (RR 1.6) and still birth (RR 1.5) are also associated with a moderate increase in CVD risk. Taking a thorough pregnancy history is important in determining future cardiovascular risk in women. The ESC guidelines give a Class IIb (LOE B) recommendation that in women with history of premature or stillbirth, periodic screening for hypertension and DM may be considered. Of note, the 2018 ACC/AHA guidelines include preeclampsia and premature menopause (occurring at age <40 years) as risk-enhancing factors for statin therapy but state that the mechanism or cause of preterm birth is often unknown, so it is difficult to include it as a risk-enhancing factor.
Choice A (sending additional lab workup including CRP and LPa) is incorrect. The ESC guidelines do not recommend using routine circulating biomarkers as they do not improve risk prediction and publication bias distorts the evidence (Class III, LOE B). While some biomarkers like lipoprotein (a) are promising, further work is still needed. Conversely, the 2019 ACC/AHA guidelines do include, if measured,
301. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #20 with Dr. Robert Mentz
May 25, 2023
The following question refers to Sections 7.3.2, 7.3.8, and 7.6.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Palisades Medical Center medicine resident & CardioNerds Intern Dr. Maryam Barkhordarian, answered first by Hopkins Bayview medicine resident & CardioNerds Academy Fellow Dr. Ty Sweeny, and then by expert faculty Dr. Robert Mentz.
Dr. Mentz is associate professor of medicine and section chief for Heart Failure at Duke University, a clinical researcher at the Duke Clinical Research Institute, and editor-in-chief of the Journal of Cardiac Failure. Dr. Mentz is a mentor for the CardioNerds Clinical Trials Network as lead principal investigator for PARAGLIDE-HF and is a series mentor for this very Decipher the Guidelines Series. For these reasons and many more, he was awarded the Master CardioNerd Award during ACC22.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #20
Ms. Betty Blocker is a 60-year-old woman with a history of alcohol-related dilated cardiomyopathy who presents for follow up. She has been working hard to improve her health and is glad to report that she has just reached her 5-year sobriety milestone. Her current medications include metoprolol succinate 100mg daily, sacubitril-valsartan 97-103mg BID, spironolactone 25mg daily, and empagliflozin 10mg daily. She is asymptomatic at rest and up to moderate exercise, including chasing her grandchildren around the yard. A recent transthoracic echocardiogram shows recovered LVEF from previously 35% now to 60%. Ms. Blocker does not love taking so many medications and asks about discontinuing her metoprolol. Which of the following is the most appropriate response to Ms. Blocker’s request?
A
Since the patient is asymptomatic, metoprolol can be stopped without risk
B
Stopping metoprolol increases this patient’s risk of worsening cardiomyopathy regardless of current LVEF or symptoms
C
Because the LVEF is now >50%, the patient is now classified as having HFpEF and beta-blockade is no longer indicated; metoprolol can be safely discontinued
D
Metoprolol should be continued, but it is safe to discontinue either ARNi or spironolactone
Answer #20
Explanation
The correct answer is B – stopping metoprolol would increase her risk of worsening cardiomyopathy.
Heart failure tends to be a chronically sympathetic state. The use of beta-blockers (specifically bisoprolol, metoprolol succinate, and carvedilol) targets this excess adrenergic output and has been shown to reduce the risk of death in patients with HFrEF. Beyond their mortality benefit, beta-blockers can improve LVEF, lessen the symptoms of HF, and improve clinical status. Therefore, in patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations (Class 1, LOE A). Beta-blockers in this setting provide a high economic value.
Table 14 of the guidelines provides recommendations for target doses for GDMT medications. Specifically for beta blockers, those targets are 25-50mg twice daily for carvedilol (or 80mg once daily for the continuous release formulation), 200mg once daily for metoprolol succinate,
300. Case Report: A Presentation of Heart Failure and Heart Block with Elusive Genetic Origins – Cambridge University
May 23, 2023
CardioNerds (Drs. Amit Goyal and Dan Ambinder) join Dr. Mina Fares, Dr. Johannes Bergehr, and Dr. Christina Peter from Cambridge University Hospitals in the UK. They discuss a case involving a man man in his 40’s presented with progressive heart failure symptoms. He has extensive background cardiac history including prior episodes of myocarditis and complete heart block status post permanent pacemaker implantation. Ultimately a diagnosis of Danon disease is made. Dr. Sharon Wilson provides the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Summary - A Presentation of Heart Failure and Heart Block with Elusive Genetic Origins - Cambridge University
A man in his 40s with a history of cardiac issues, including prior myocarditis and complete heart block, presented with progressive heart failure symptoms. Extensive cardiac investigations were conducted, revealing dilated left ventricle, mild to moderate left ventricular systolic dysfunction, normal coronaries, infero-lateral late gadolinium enhancement on cardiac MRI, and low-level uptake on PET-CT. Differential diagnosis included worsening underlying cardiomyopathy, recurrent myocarditis, tachycardia-related cardiomyopathy, pacemaker-induced LV dysfunction, and sarcoidosis. The patient's condition improved with heart failure medications, and cardiac MRI showed a mildly dilated left ventricle with moderate systolic dysfunction and active inflammation in the anterior wall. Further evaluation indicated a family history of hereditary cardiomyopathy, and the patient exhibited phenotypic features such as early-onset heart disease, arrhythmias, family history of cardiomyopathy, learning problems, intellectual disability, and mild proximal myopathy. Genetic testing confirmed a LAMP2 mutation, leading to the diagnosis of Danon disease.
Case Media - A Presentation of Heart Failure and Heart Block with Elusive Genetic Origins - Cambridge University
Show Notes -A Presentation of Heart Failure and Heart Block with Elusive Genetic Origins - Cambridge University
References -
Danon, M. J., Oh, S. J., DiMauro, S., Miranda, A., De Vivo, D. C., & Rowland, L. P. (1981). Lysosomal glycogen storage disease with normal acid maltase. Neurology, 31(1), 51-7.
Nishino, I., Fu, J., Tanji, K., Nonaka, I., & Ozawa, T. (2000). Mutations in the gene encoding LAMP2 cause Danon disease. Nature, 406(6798), 906-10.
Tanaka, K., Nishino, I., Nonaka, I., Fu, J., & Ozawa, T. (2000). Danon disease is caused by mutations in the gene encoding LAMP2, a lysosomal membrane protein. Nature, 406(6798), 902-6.
Maron, B. J., Haas, T. S., Ackerman, M. J., Ahluwalia, A., Spirito, P., Nishino, I., ... & Seidman, C. E. (2009). Hypertrophic cardiomyopathy and sudden death in a family with Danon disease. JAMA, 301(12), 1253-9.
Hashem, S., Zhang, J., Zhang, Y., Wang, H., Zhang, H., Liu, L., ... & Wang, J. (2015). AAV-mediated gene transfer of LAMP2 improves cardiac function in Danon disease mice. Stem cells, 33(11), 2343-2350.
Chi, L., Wang, H., Zhang, J., Zhang, Y., Liu, L., Wang, J., ... & Hashem, S. (2019). CRISPR/Cas9-mediated gene editing of LAMP2 in patient-derived iPSCs ameliorates Danon disease phenotypes.
299. Guidelines: 2021 ESC Cardiovascular Prevention – Question #25 with Dr. Eugene Yang
May 15, 2023
The following question refers to Section 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Mayo Clinic Fellow Dr. Teodora Donisan, and then by expert faculty Dr. Eugene Yang.Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and chair of the ACC Prevention of CVD Section.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #25
Please choose the CORRECT statement from the ones below.ACAC scoring can be considered to improve ASCVD risk classification around treatment decision thresholds.BPatients with type 1 or type 2 diabetes are considered very high CV risk, regardless of comorbidities and other risk factors.CCKD does not increase the cardiovascular risk in the absence of other risk factors.DMen and women older than 65 years old are at high cardiovascular risk.
Answer #25
ExplanationOption A is correct. Coronary artery calcium (CAC) scoring can reclassify CVD risk upwards and downwards in addition to conventional risk factors and may thus be considered in men and women with calculated risks around decision thresholds (Class IIb, Level B). If CAC is detected, its extent should be compared with what would be expected for a patient of the same sex and age. CAC scoring does not provide direct information on total plaque burden or stenosis severity and can be low or even zero in middle-aged patients with soft non-calcified plaque.Option B is false. Not all patients with diabetes are very high risk by default.· Moderate risk: well controlled diabetes, <10 years duration, without evidence of target organ damage and no additional ASCVD risk factors.· High risk: patients not fulfilling the criteria above, without ASCVD and/or severe target organ damage.· Very high risk: diabetic patients with established ASCVD and/or severe target organ damage.Severe target organ damage is defined by:· eGFR <45 mL/min/1.73 m2· eGFR 45-59 mL/min/1.73 m2 and microalbuminuria (albumin-to-creatinine ratio, ACR 30 -300 mg/g)· Proteinuria (ACR >300 mg/g)· Presence of microvascular disease in at least 3 different sites (e.g., microalbuminuria + retinopathy + neuropathyOption C is false. CKD carries at least a high CVD risk even in the absence of diabetes or ASCVD.· Moderate CKD carries a high CVD risk: o eGFR 30−44 mL/min/1.73 m2 and ACR <30o eGFR 45−59 mL/min/1.73 m2 and ACR 30−300o eGFR ≥60 mL/min/1.73 m2 and ACR >300· Severe CKD carries a very high CVD risk:o eGFR<30 mL/min/1.73 m2o eGFR 30−44 mL/min/1.73 m2 and ACR >30 Option D is false. There is an age difference between men and women with regards to cardiovascular risk. Age is a major CVD risk driver, but age cutoffs should be used with flexibility.· Women < 50 years-old and men < 40 years old are usually at low 10-year CVD risk. It is still important to be aware of unfavorable modifiable risk factors that can sharply increase their lifetime CVD risk.· Women > 75 years-old and men > 65 years-old are usually at high 10-year CVD risk.· Only between the ages of 55 – 75 years in women and 40 – 65 years in men does the 10-year CVD risk vary around commonly used thresholds for intervention. Of note:· In younger, apparently healthy patients, we also discuss lifetime CVD risk estimates since 10-year risk assessments often underestimate risk.
298. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #19 with Dr. Clyde Yancy
May 12, 2023
The following question refers to Section 7.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Lahey Hospital and Medical Center internal medicine resident and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Clyde Yancy.
Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the ACC/AHA Joint Committee on Clinical Practice Guidelines.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #19
Ms. M is a 36-year-old G1P1 woman 6 months postpartum who was diagnosed with peripartum cardiomyopathy at the end of her pregnancy. She is presenting for a follow up visit today and notes that while her leg edema has resolved, she continues to have dyspnea when carrying her child up the stairs. She also describes significant difficulty sleeping, though denies orthopnea, and notes she is not participating in hobbies she had previously enjoyed. She is currently prescribed a regimen of sacubitril-valsartan, metoprolol succinate, spironolactone, and empagliflozin. What are the next best steps?
A
Screen for depression
B
Counsel her to follow a strict low sodium diet with goal of < 1.5g Na daily
C
Recommend exercise therapy and refer to cardiac rehabilitation
D
A & C
Answer #19
Explanation
The correct answer is D – both A (screening for depression) and C (referring to cardiac rehabilitation) are appropriate at this time.
Choice A is correct. Depression is a risk factor for poor self-care, rehospitalization, and all-cause mortality among patients with HF. Interventions that focus on improving HF self-care have been reported
to be effective among patients with moderate/severe depression with reductions in hospitalization and mortality risk. Social isolation, frailty, and marginal health literacy have similarly been associated with poor HF self-care and worse outcomes in patients with HF. Therefore, in adults with HF, screening for depression, social isolation, frailty, and low health
literacy as risk factors for poor self-care is reasonable to improve management (Class 2a, LOE B-NR).
Choice C is correct. In patients with HF, cardiac rehabilitation has a Class 2a recommendation (LOE B-NR) to improve functional capacity, exercise tolerance, and health-related QOL; exercise training (or regular physical activity) for those able to participate has a Class 1 recommendation (LOE A) to improve functional status, exercise performance, and QOL.
Choice B is incorrect. For patients with stage C HF, avoiding excessive sodium intake is reasonable to reduce congestive symptoms (Class 2a, LOE C-LD). However, strict sodium restriction does not have strong supportive data and is not recommended. There are ongoing studies to better understand the impact of sodium restriction on clinical outcomes and quality of life. The AHA currently recommends a reduction of sodium intake to <2300 mg/d for general cardiovascular health promotion; however, there are no trials to support this level of restriction in patients with HF.
Main Takeaway
Depression is a risk factor for poor HF self-care and worse outcomes in pat...
297. Case Report: A Sinister Cause of Sudden Cardiac Death – University of Washington
May 10, 2023
CardioNerds (Daniel Ambinder) join Dr. Tomio Tran, Dr. Vid Yogeswaran, and Dr. Amanda Cai from the University of Washington for a break from the rain at the waterfront near Pike Place Market. They discuss the following case: A 46-year-old woman presents with cardiac arrest and was found to have cor triatriatum sinistrum (CTS). CTS is a rare congenital cardiac malformation in which the left atrium is divided by a fenestrated membrane, which can restrict blood flow and cause symptoms of congestive heart failure. Rarely, the condition can present in adulthood. To date, there have been no cases of sudden cardiac death attributed to CTS. Dr. Jill Steiner provides the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Media - A Sinister Cause of Sudden Cardiac Death – University of Washington
A 40-year-old woman with a history of recurrent exertional syncope had sudden loss of consciousness while kissing her partner. The patient received bystander CPR while 911 was called. EMS arrived within 10 minutes of the call and found the patient apneic and unresponsive. Initial rhythm check showed narrow complex tachycardia at a rate of 136 BPM. ROSC was eventually achieved. A 12-lead ECG showed that the patient was in atrial fibrillation with rapid ventricular rate. The patient was intubated and brought to the emergency department. The patient spontaneously converted to sinus rhythm en route to the hospital.
In the emergency department, vital signs were remarkable for hypotension (76/64 mmHg) and sinus tachycardia (110 BPM). The physical exam was remarkable for an inability to follow commands. Laboratory data was remarkable for hypokalemia (2.5 mmol/L), transaminitis (AST 138 units/L, ALT 98 units/L), acidemia (pH 7.12), and hyperlactatemia (11.2 mmol/L). CT scan of the chest revealed a thin membrane within the left atrium. Transthoracic echocardiogram showed normal biventricular size and function, severe tricuspid regurgitation, pulmonary artery systolic pressure of 93 mmHg, and the presence of a membrane within the left atrium with a mean gradient of 25 mmHg between the proximal and distal left atrial chambers. Vasopressors and targeted temperature management were initiated.
The patient was able to be re-warmed with eventual discontinuation of vasopressors, however she had ongoing encephalopathy and seizures concerning for hypoxic brain injury. There was discussion with the adult congenital heart disease team about next steps in management, however the patient was too sick to undergo any definitive treatment for the intracardiac membrane within the left atrium. The patient developed ventilator associated pneumonia and antibiotics were initiated. The patient ultimately developed bradycardia and pulseless electrical activity; ROSC was unable to be achieved, resulting in death.
Autopsy was remarkable for the presence of a fenestrated intracardiac membrane within the left atrium and lack of other apparent congenital heart defects. There was right ventricular hypertrophy and pulmonary artery intimal thickening with interstitial fibrosis suggestive of pulmonary hypertension. There were bilateral acute subsegmental pulmonary emboli present. The cause of death was declared to be arrhythmia in the setting of pulmonary hypertension and right s...
296. Guidelines: 2021 ESC Cardiovascular Prevention – Question #24 with Dr. Jaideep Patel
May 05, 2023
The following question refers to Section 6.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD cardiology fellow Dr. Harpreet Bhatia, and then by expert faculty Dr. Jaideep Patel.Dr. Patel recently graduated from Virginia Commonwealth University cardiology fellowship and is now a preventive cardiologist at the Johns Hopkins Hospital.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #24
A 65-year-old man with a history of ischemic stroke 6 months ago presents to cardiology clinic to establish care. An event monitor was negative for atrial fibrillation and TTE with agitated saline study was negative for a patent foramen ovale. Therefore, his ischemic stroke was presumed to be non-cardioembolic in origin. He is currently taking lisinopril 5 mg daily for hypertension (BP in clinic is 115/70) and atorvastatin 40 mg daily. He has no history of significant gastrointestinal or other bleeding. What do you recommend next?AStart apixaban 5 mg BIDBIncrease lisinopril to 10 mg dailyCStart aspirin 81 mg dailyDStart aspirin 81 mg daily and clopidogrel 75 mg dailyEStart aspirin 81 mg daily and ticagrelor 90 mg BID
Answer #24
ExplanationThe correct answer is C – start aspirin 81mg daily.For the secondary prevention of non-cardioembolic ischemic stroke or TIA, anti-platelet therapy is recommended with aspirin only (75-150 mg/day), dipyridamole + aspirin (slightly superior to aspirin), or clopidogrel alone (slightly superior to aspirin) (Class I, LOE A).DAPT with aspirin and clopidogrel or aspirin and ticagrelor should be considered in the immediate period after a minor ischemic stroke or TIA (3 weeks after event, Class IIa), but not 6 months after an ischemic stroke. Dual antiplatelet therapy with aspirin and clopidogrel increases bleeding risk without a significant benefit over either agent alone. Dual antiplatelet therapy with aspirin and ticagrelor increases bleeding risk, but does not improve disability incidence.Oral anticoagulation would be recommended for a cardioembolic stroke, which does not fit the clinical picture.His BP is well controlled so increasing lisinopril is not necessary.Main TakeawayFor the secondary prevention of an ischemic stroke or TIA, anti-platelet therapy with aspirin, aspirin + dipyridamole, or clopidogrel alone is recommended.Guideline Loc.6.3, page 3296-3297
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295. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #18 with Dr. Shelley Zieroth
May 04, 2023
The following question refers to Sections 3.2, 4.1, 4.3, and 4.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Baylor University cardiology fellow and CardioNerds FIT Trialist Dr. Shiva Patlolla, and then by expert faculty Dr. Shelley Zieroth.
Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She is a steering committee member for PARAGLIE-HF and a PI Mentor for the CardioNerds Clinical Trials Program.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #18
Ms. AH is a 48-year-old woman who presents with a 3-month history of progressively worsening exertional dyspnea and symmetric bilateral lower extremity edema. She has no history of recent upper respiratory symptoms or chest pain.
She denies any tobacco, alcohol, or recreational drug use. There is no family history of premature CAD or HF.
On exam, her blood pressure is 110/66 mmHg, heart rate is 112 bpm, and respiration rate is 18 breaths/min with oxygen saturation of 98% on ambient room air. She has jugular venous distention of about 12cm H2O, bibasilar crackles, an S3 heart sound, and bilateral lower extremity edema.
Complete blood count, serum electrolytes, kidney function tests, liver chemistry tests, glucose level, iron studies, and lipid levels are unremarkable.
An electrocardiogram shows sinus tachycardia with normal intervals and no conduction delays. A transthoracic echocardiogram demonstrates a left ventricular ejection fraction of 25%, normal right ventricular size and function, and no valvular abnormalities.
Which of the following diagnostic tests has a Class I indication for further evaluation?
A
Cardiac catheterization
B
Referral for genetic counseling
C
Thyroid function studies
D
Cardiac MRI
Answer #18
Explanation
The correct answer is C – thyroid function studies have a Class 1 indication for the evaluation of HF.
The common causes of HF include coronary artery disease, hypertension, and valvular heart disease. Other causes may include arrhythmia-associated, toxic, inflammatory, metabolic including both endocrinopathies and nutritional, infiltrative, genetic, stress induced, peripartum, and more. It is important to evaluate for the etiology of a given patient’s heart failure as diagnosis may have implications for treatment, counseling, and family members.
For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management (Class 1, LOR C-EO). These studies provide important information regarding comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, and severity and prognosis of HF.
294. ACHD: Interventional Cardiology with Dr. Jamil Aboulhosn and Dr. Joanna Ghobrial – Part 2
May 02, 2023
CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional cardiology procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
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Pearls - ACHD: Interventional Cardiology
The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass
Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.
Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.
As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate.
Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).
Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.
Notes- ACHD: Interventional Cardiology
1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:
Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.
Bioprosthetic Valves. (Valve in Valve TPVR)
Native outflow tract
2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?
Coronary artery compression
Conduit rupture
Vessel injury (including the pulmonary bed)
Valve embolization
Endocarditis
3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?
You will see higher CVPs in patients with a Fontan palliation.
293. ACHD: Interventional Cardiology with Dr. Jamil Aboulhosn and Dr. Joanna Ghobrial – Part 1
May 01, 2023
CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
Pearls - ACHD: Interventional Cardiology
The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass
Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.
Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.
As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate.
Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).
Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.
Notes- ACHD: Interventional Cardiology
1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:
Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.
Bioprosthetic Valves. (Valve in Valve TPVR)
Native outflow tract
2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?
Coronary artery compression
Conduit rupture
Vessel injury (including the pulmonary bed)
Valve embolization
Endocarditis
3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?
You will see higher CVPs in patients with a Fontan palliation.
292. Guidelines: 2021 ESC Cardiovascular Prevention – Question #23 with Dr. Eugenia Gianos
Apr 30, 2023
The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by Houston Methodist medicine resident Dr. Najah Khan, and then by expert faculty Dr. Eugenia Gianos.Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the director of Women s Heart Health at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #23
An asymptomatic 55-year-old man with no past medical history presents to clinic after having a cardiac CT as part of an executive physical. His coronary artery calcium (CAC) score was 200 and the coronary CTA demonstrated isolated 70% stenosis of the left circumflex coronary artery. He is asymptomatic and able to jog 2 miles daily without limitation. He was recently started on aspirin 81 mg daily and atorvastatin 40 mg daily by his primary care provider. His LDL is 50 mg/dL, HbA1c is 6.0%. His BP is 108/70. What would you recommend?AStop aspirin 81 mg daily as he has not had an ASCVD event or revascularizationBCardiac catheterization and stent placement in the left circumflexCIncrease atorvastatin to 80 mg dailyDStress testENo change in management
Answer #23
Answer choicesAStop aspirin 81 mg daily as he has not had an ASCVD event or revascularizationBCardiac catheterization and stent placement in the left circumflexCIncrease atorvastatin to 80 mg dailyDStress testENo change in managementExplanationThe correct answer is E – no change in management.Though the patient has not had an ASCVD event or revascularization, low-dose aspirin may be considered with definite evidence of CAD on imaging (Class IIb, LOE C).He is asymptomatic and does not have high risk anatomy on CT (i.e., proximal LAD, left main disease, multivessel disease), so percutaneous coronary intervention or stress testing are not indicated.His LDL is well controlled, so increasing atorvastatin would not be appropriate at this time.Main TakeawayAspirin 75-100 md daily may be considered in the absence of MI or revascularization when there is definitive evidence of CAD on imaging (Class IIb, LOE C).Guideline Loc.Section 6.1
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291. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #17 with Dr. Biykem Bozkurt
Apr 28, 2023
The following question refers to Section 5.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Greater Baltimore Medical Center medicine resident / Johns Hopkins MPH student and CardioNerds Academy House Chief Dr. Alaa Diab, and then by expert faculty Dr. Biykem Bozkurt.
Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, and current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #17
A 63-year-old man with CAD s/p CABG 3 years prior, type 2 diabetes mellitus, hypertension, obesity, and tobacco use disorder presents for routine follow-up. His heart rate is 65 bpm and blood pressure is 125/70 mmHg. On physical exam, he is breathing comfortably with clear lungs, with normal jugular venous pulsations, a regular rate and rhythm without murmurs or gallops, and no peripheral edema. Medications include aspirin 81mg daily, atorvastatin 80mg daily, lisinopril 20mg daily, and metformin 1000mg BID. His latest hemoglobin A1C is 7.5% and recent NT-proBNP was normal. His latest transthoracic echocardiogram showed normal biventricular size and function. Which of the following would be a good addition to optimize his medical therapy?
A
DPP-4 inhibitor
B
Dihydropyridine calcium channel blocker
C
SGLT2 inhibitor
D
Furosemide
Answer #17
Explanation
The correct answer is C: SGLT2 inhibitor.
This patient is at risk for HF (Stage A) given absence of signs or symptoms of heart failure but presence of coronary artery disease and several risk factors including diabetes, hypertension, obesity, and tobacco smoking. At this stage, the focus should be on risk factor modification and prevention of disease onset.
Healthy lifestyle habits such as maintaining regular physical activity; normal weight, blood pressure, and blood glucose levels; healthy dietary patterns, and not smoking have been associated with a lower lifetime risk of developing HF.
Multiple RCTs in patients with type 2 diabetes who have established CVD or are at high risk for CVD, have shown that SGLT2i prevent HF hospitalizations compared with placebo. The benefit for reducing HF hospitalizations in these trials predominantly reflects primary prevention of symptomatic HF, because only approximately 10% to 14% of participants in these trials had HF at baseline.
As such, in patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF (Class 1, LOE A).
The mechanisms for the improvement in HF events from SGLT2i have not been clearly elucidated but seem to be independent of glucose lowering. Proposed mechanisms include reductions in plasma volume, cardiac preload and afterload, alterations in cardiac metabolism, reduced arterial stiffness, and interaction with the Na+/H+ exchanger. SGLT2i are generally well tolerated,
290. Guidelines: 2021 ESC Cardiovascular Prevention – Question #22 with Dr. Eileen Handberg
Apr 23, 2023
The following question refers to Section 4.6 of the 2021 ESC CV Prevention Guidelines. The question is asked by Student Dr. Shivani Reddy, answered first by Johns Hopkins Cardiology Fellow Dr. Rick Ferraro, and then by expert faculty Dr. Eileen Handberg.
Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President for the PCNA.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #22
Mr. HC is a 50-year-old man presenting for a routine clinic visit. He is not sure the last time he had a lipid panel drawn, and would like one today, but ate lunch just prior to your appointment – a delicious plate of 50% fruits and vegetables, 25% lean meats, and 25% whole grains as you had previously recommended.
True or False: Mr. HC should return another day to obtain a fasting lipid panel.
TRUE
FALSE
Answer #22
Answer choices
TRUE
FALSE
Explanation
This statement is False. A non-fasting lipid panel is appropriate for risk stratification and lipid evaluation in most patients per the ESC guidelines.
While no level of evidence in provided in the ESC guidelines, this recommendation is consistent with AHA/ACC cholesterol guidelines, which have also largely moved away from fasting lipid panels for most patients and give a Class 1 (LOE B) recommendation to obtaining a fasting or nonfasting plasma lipid profile for ASCVD estimation and baseline LDL-C in adults 20 years of age or older.
The ESC recommendation is based upon large trials showing that results of fasting and non-fasting panels are largely similar. This is similar to the AHA/ACC guidelines, which note non-fasting and fasting LDL-C change minimal over time following a normal meal, while HDL-C and tryiglycerides appear to have similar prognostic significance with cardiovascular outcomes in fasting or nonfasting states.
A fasting lipid panel should be considered in those with hypertriglyceridemia, metabolic syndrome, and diabetes mellitus, as consumption of food or drink can have direct and immediate effects on TG and blood glucose values.
Main Takeaway
A non-fasting lipid panel is appropriate for the majority of patients undergoing lipid evaluation and cardiovascular risk stratification.
Guideline Loc.
Section 4.6.1
CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series
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289. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #16 with Dr. Harriette Van Spall
Apr 19, 2023
The following question refers to Sections 11.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Johns Hopkins Osler internal medicine resident and CardioNerds Academy Fellow Dr. Justin Brilliant, and then by expert faculty Dr. Harriette Van Spall.
Dr. Van Spall is Associate Professor of Medicine, cardiologist, and Director of E-Health at McMaster University. Dr Van Spall is a Canadian Institutes of Health Research-funded clinical trialist and researcher with a focus on heart failure, health services, and health disparities.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #16
Ms. Augustin is a 33 y/o G1P1 woman from Haiti who seeks counseling regarding family planning as she and her husband dream of a second child. Her 1st pregnancy 12 months ago was complicated by pre-eclampsia and peripartum cardiomyopathy (LVEF 35%). Thankfully she delivered a healthy baby via C-section. She has no other past medical history and is currently on losartan 25 mg daily and metoprolol succinate 200 mg daily. She has been asymptomatic. Which of the following statements is recommended to medically optimize Ms. Augustin prior to her 2nd pregnancy?
A
No medical optimization or preconception planning is needed as her 1st pregnancy resulted in a healthy infant.
B
Discontinue losartan and metoprolol with no other needed pregnancy planning
C
Change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy
D
Continue losartan and metoprolol and advise against repeat pregnancy
Answer #16
Explanation
The correct answer is C – change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy.
Heart failure may complicate pregnancy either secondary to an existing pre-pregnancy cardiomyopathy or as a result of peripartum cardiomyopathy. In women with history of heart failure or cardiomyopathy, including previous peripartum cardiomyopathy, patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy should be provided (Class I, LOE C-LD)
Peripartum cardiomyopathy (PPCM) is defined as systolic dysfunction, typically LVEF < 45%, often with LV dilation, occurring in late pregnancy or early postpartum with no other identifiable etiology. PPCM occurs worldwide, with the highest incidences in Haiti, Nigeria, and South Africa. Other clinical risk factors include maternal age > 30 years, African ancestry, multiparity, multigestation, preeclampsia/eclampsia, anemia, diabetes, obesity, and prolonged tocolysis.
The pathogenesis of peripartum cardiomyopathy is complex and it is likely a multifactorial process. The combination of hemodynamic changes of pregnancy, inflammation of the myocardium, hormonal changes, genetic factors, and an autoimmune response have all been proposed as possible mechanisms and these may certainly be interrelated.
While pregnancy is generally well-tolerated in women with cardiomyopathy and NYHA class I status pre-pregnancy, clinical deterioration can occur and so counseling a...
288. 2nd Annual Sanjay V. Desai Lecture: The Humanity Deficiency in Medicine with Dr. Melanie Sulistio
Apr 18, 2023
The CardioNerds Academy welcomes Dr. Melanie Sulistio to give the 2nd Annual Sanjay V. Desai Lecture in Medical Education to mark the graduation of the 2022 CardioNerds Academy Class. Join us as Dr. Sulistio and CardioNerds Academy Program Director Dr. Tommy Das discuss the humanity deficiency in medicine, and how the practice of compassionate assumption can lead us to be better physicians for our patients, our colleagues, our learners, and ourselves. Credit to rising CardioNerds Academy chiefs Dr. Rawan Amir, Dr. Kate Wilcox, Dr. Alaa Diab, and Dr. Gurleen Kaur for their terrific acting in this episode. Audio editing by CardioNerds academy intern, Pace Wetstein.
Dr. Sanjay V Desai serves as the Chief Academic Officer, The American Medical Association and is the former Program Director of the Osler Medical Residency at The Johns Hopkins Hospital.
Dr. Melanie Sulistio is an Associate Professor of Medicine in the Division of Cardiology at the University of Texas Southwestern. Additionally, she is an Associate Dean for Student Affairs and Distinguished Teaching Professor at the University of Texas Southwestern Medical School and co-chairs the ACC Internal Medicine Residency Program. She has a passion for medical education and promoting humanity in medicine, and is actively involved in the work of teaching communication skills that encompass meaningful care, discussions with patients, and difficult conversations with colleagues.
Relevant disclosures: None
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287. Case Report: When Tumors Take Your Breath Away – University of Oklahoma College of Medicine
Apr 14, 2023
CardioNerds join Dr. Samid Muhammad Farooqui, Dr. Hiba Hammad, and Dr. Syed Talal Hussain, from the University of Oklahoma Pulmonary and Critical Care Medicine Fellowship Program, in Oklahoma City. The fellows will take us in a fascinating discussion of a case of rapidly progressing dyspnea and pulmonary hypertension in a patient with metastatic breast cancer. They will then reveal an interesting etiology of pulmonary hypertension, where the secret was on the wedge! University of Oklahoma faculty and expert in pulmonary hypertension and right ventricular physiology, Dr. Roberto J. Bernardo provides the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen.
A septuagenarian female, with a past medical history of metastatic breast adenocarcinoma, presented to the hospital with worsening dyspnea over a period of 3 weeks. She was found to be in rapidly progressive hypoxic respiratory failure with unremarkable chest x-ray, CTA chest, and V/Q scan. Transthoracic echocardiogram revealed elevated RVSP and a subsequent right heart catheterization showed pre-capillary pulmonary hypertension with a low cardiac index. She was treated for rapidly progressive RV dysfunction with inotropic support and inhaled pulmonary vasodilators until she decided to pursue comfort measures. Wedge cytology came back positive for malignant cells, confirming a diagnosis of Pulmonary Tumoral Thrombotic Microangiopathy (PTTM).
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Media - When Tumors Take Your Breath Away - University of Oklahoma College of Medicine
Pearls - When Tumors Take Your Breath Away - University of Oklahoma College of Medicine
Pulmonary arterial hypertension (PAH) is a progressive disorder of the pulmonary vasculature, characterized by progressive obliteration and remodeling of the pulmonary circulation, resulting in increased pulmonary vascular resistance and increased right ventricular (RV) wall stress, abnormal right ventricular mechanics, and eventually RV dysfunction and death.
Pulmonary hypertension (PH) is divided into pre-capillary and post-capillary profiles, where pre-capillary PH is hemodynamically characterized by a mean pulmonary artery pressure (mPAP) > 20 mmHg, pulmonary artery wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance (PVR) ≥ 3 Woods Units (WU), and post-capillary PH is defined as mPAP > 20 mmHg, PAWP ≥ 15 mmHg, and PVR can be either < 3 WU (isolated post-capillary PH) or ≥ 3 WU (combined pre- and post-capillary PH). Pulmonary arterial hypertension (PAH) falls under the pre-capillary PH profile.
Dyspnea on exertion is the most common manifestation of PH, and the most common initial complain. Other symptoms and physical findings such as venous congestion, peripheral edema, signs of RV dysfunction or syncope present later in the disease course. As such, PH has to be considered in the differential diagnosis of dyspnea, especially in cases of undifferentiated or unexplained dyspnea.
PAH is a chronic but progressive condition, where symptoms progress over the course of months to years. Subacute or rapidly progressive forms of PH (symptoms rapidly worsening over the course of weeks) should warrant consideration for alternative etiologies (i.e., pulmonary embolism or a different cardiopulmonary disorder as the main d...
286. Guidelines: 2021 ESC Cardiovascular Prevention – Question #21 with Dr. Noreen Nazir
Apr 11, 2023
The following question refers to Section 4.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by medicine resident Dr. Ahmed Ghoneem, and then by expert faculty Dr. Noreen Nazir.
Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #21
Ms. J is a 57-year-old woman with a past medical history of myocardial infarction resulting in ischemic cardiomyopathy, heart failure with reduced ejection fraction, and major depressive disorder who presents today for follow-up. She reports feeling extremely overwhelmed lately due to multiple life stressors. She is on appropriate cardiovascular GDMT agents and is not prescribed any medications for her mood disorder.
True or false: in addition to psychotherapy for stress management, it is appropriate to consider Ms. J for anti-depressant SSRI pharmacotherapy at this time to improve cardiovascular outcomes.
A
True
B
False
Answer #21
Explanation
The correct answer is FALSE.
An ESC class 3 recommendation states that SSRIs, SNRIs, and tricyclic antidepressants are not recommended in patients with heart failure and major depression; this is based on data suggesting potential lack of SSRI efficacy for reducing depression or cardiovascular events, as well as safety data indicating an association between SSRI use and increased risk of CV events and all-cause as well as cardiovascular mortality among HF patients. Mental health disorders are associated with worse outcomes in patients with ASCVD and appropriate treatment effectively reduces stress symptoms and improves quality of life. Nonpharmacologic modalities of treatment (exercise therapy, psychotherapy, collaborative care) should be considered before pharmacotherapy to improve cardiovascular outcomes in patients with heart failure.
Of note, the ESC suggests SSRI treatment be considered for patients with coronary heart disease (without HF) and moderate-to-severe major depression based on data that SSRI treatment is associated with lower rates of CHD readmission (RR 0.63), all-cause mortality (RR 0.56), and the composite endpoint of all-cause mortality/MI/PCI (HR 0.69) vs. no treatment. This is a class 2a recommendation.
ESC also gives a class 2a recommendation to consider referral to psychotherapeutic stress management for individuals with stress and ASCVD to improve CV outcomes and reduce stress symptoms.
The ACC/AHA guidelines do not provide focused recommendations regarding mental health considerations in patients with elevated cardiovascular risk.
Main Takeaway
It is important to consider mental health treatment in patients with ASCVD as mental disorders are associated with increased CVD risk and poor patient prognosis, and data support that mental health interventions can improve overall and CVD outcomes, as well as improve quality of life.
Guideline Loc.
Section 4.4
CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series
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285. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #15 with Dr. Ileana Pina
Apr 11, 2023
The following question refers to Section 10.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Boston University cardiology fellow and CardioNerds Ambassador Dr. Alex Pipilas, and then by expert faculty Dr. Ileana Pina.Dr. Pina is Professor of Medicine and Quality Officer for the Cardiovascular Line at Thomas Jefferson University, Clinical Professor at Central Michigan University, and Adjunct Professor of Biostats and Epidemiology at Case Western University. She serves as Senior Fellow and Medical Officer at the Food and Drug Administration’s Center for Devices and Radiological Health.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #15
Mrs. Framingham is a 65-year-old woman who presents to her cardiologist’s office for stable angina and worsening dyspnea on minimal exertion. She has a history of non-insulin dependent type 2 diabetes mellitus and hypertension. She is taking metformin, linagliptin, lisinopril, and amlodipine. Blood pressure is 119/70 mmHg. Labs are notable for a hemoglobin of 14.2 mg/dL, iron of 18 mcg/dL, ferritin 150 ug/L, transferrin saturation 15%, and normal creatine kinase. An echocardiogram shows reduced left ventricular ejection fraction of 25%. Coronary angiography shows obstructive lesions involving the proximal left anterior descending, left circumflex, and right coronary arteries. In addition to optimizing GDMT, which of the following are recommendations for changes in management?
A
Anticoagulation, percutaneous revascularization, and IV iron
B
A change in her diabetic regimen, percutaneous revascularization, and PO iron
C
A change in her diabetic regimen, surgical revascularization, and IV iron
D
A change in her diabetic regimen, medical treatment alone for CAD, and PO iron
E
Anticoagulation and surgical revascularization
Answer #15
Explanation
The correct answer is C – a change in her diabetic regimen, surgical treatment and IV iron.
Multimorbidity is common in patients with heart failure. More than 85% of patients with HF also have at least 2 additional chronic conditions, of which the most common are hypertension, ischemic heart disease, diabetes, anemia, chronic kidney disease, morbid obesity, frailty, and malnutrition. These conditions can markedly impact patients’ tolerance to GDMT and can inform prognosis.
Not only was Mrs. F found with HFrEF (most likely due to ischemic cardiomyopathy), but she also suffers from severe multi-vessel coronary artery disease, hypertension, and non-insulin dependent type 2 diabetes mellitus.
In addition to starting optimized GDMT for HF, specific comorbidities in the heart failure patient warrant specific treatment strategies. Mrs. Framingham would benefit from a change in her diabetic regimen, namely switching from linagliptin to an SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin). In patients with HF and type 2 diabetes, the
use of SGLT2i is recommended for the management of hyperglycemia and to reduce HF related morbidity and mortality (Class 1, LOE A).
Furthermore, as she has diabetes, symptomatic severe multi-vessel CAD, and LVEF≤35%,
284. Atrial Fibrillation: Mechanical Stroke Prevention in Atrial Fibrillation with Dr. Christopher Ellis
Apr 10, 2023
CardioNerds Amit Goyal, Dr. Colin Blumenthal, Dr. Kelly Arps and Dr. Justice Oranefo discuss mechanical stroke prevention in atrial fibrillation with Dr. Christopher Ellis, cardiac electrophysiology lab director and director of the left atrial appendage closure program at Vanderbilt University. There has been a significant increase in the number of patients undergoing left atrial appendage occlusion (LAAO). This trend is expected to continue with current and upcoming clinical data on this topic. In this episode we dive into the rationale behind LAAO and explore several historical facts. We then proceed to the current state of practice including currently available options, appropriate indications, post op care, and potential complications. Notes were drafted by Dr. Justice Oranefo. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This series is supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
We have collaborated with VCU Health to provide CME. Claim free CME here!
Disclosures: Dr. Ellis discloses grant or research support from Boston Scientific, Abbott-St Jude, advisor for Atricure and Medtronic.
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Pearls and Quotes - Atrial Fibrillation: Mechanical Stroke Prevention in Atrial fibrillation
Surgical or catheter based left atrial appendage occlusion results in mechanical exclusion of the left atrial appendage, which is the most common source of thrombus leading to embolic events in patients with non-rheumatic atrial fibrillation.
Surgical LAAO should be considered in patients with atrial fibrillation and CHA2DS2VASC score ≥ 2 undergoing cardiac surgery for other indications.
Endocardial LAAO devices such as WATCHMAN FLX and AMULET are approved for stroke prevention in patients with atrial fibrillation with a CHA2DS2VASC score ≥ 2 and have an appropriate reason to seek a non-drug alternative to anticoagulation therapy.
Appropriate patient selection and post-operative anticoagulation and imaging strategy are crucial for prevention and management of complications related to LAAO.
Notes - Atrial Fibrillation: Mechanical Stroke Prevention in Atrial fibrillation
What are the types of LAAO device?
Left atrial appendage occlusion devices can be divided into epicardial closure and endocardial closure.
Epicardial techniques/devices include surgical ligation, Atriclip, and Lariat. These techniques require pericardial access (either by open thoracotomy or thoracoscopic access). The goals are complete exclusion and ischemic necrosis of the LAA.
LARIAT device
Atriclip device
Endocardial techniques include WATCHMAN FLX and AMULET devices. These techniques require the use of nitinol-based devices which are delivered into the LAA via a transeptal approach. These devices become endothelialized over time resulting in occlusion of the LAA.
AMULET device
WATCHMAN FLX
Who is the ideal candidate for surgical LAAO?
Several studies have evaluated the efficacy of surgical LAA occlusion. The most prominent being the LAOS III trial which randomized 4770 patients with atrial fibrillation and CHA2DS2VASC ≥ 2 undergoing cardiac surgery for other reasons to surgical LAAO vs no LAAO (3,4). The primary outcome of ischemic stroke or systemic embolization occurred in 4.8% of patients in the LAAO group vs 7% of patients in control group over an average ...
283. CardioNerds Rounds: Challenging Cases – Cardio-Obstetrics and Heart Failure with Dr. Mary Norine (Minnow) Walsh
Apr 05, 2023
It’s another session of CardioNerds Rounds! In these rounds, Dr. Jenna Skowronski (Chief FIT at University of Pittsburgh) and Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) join transformational leader, educator and researcher, Dr. Mary Norine Walsh (Director of Heart Failure and Transplantation at Ascension St. Vincent Heart Center and Program Director of AHFT at St. Vincent) to discuss cardio-obstetrics and heart failure cases. Amongst her many accomplishments, Dr. Walsh is past president of the American College of Cardiology, Deputy Editor of JACC Case Reports, and a preeminent voice and thought leader in women’s cardiovascular health. Audio editing by CardioNerds academy intern, Pace Wetstein.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
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Show notes - Cardio-Obstetrics and Heart Failure
Case 1 Synopsis:
A woman in her earlier 30s, G1P1, with a history significant for peripartum cardiomyopathy presents to clinic for pre-conception counseling. Her prior pregnancy was in her late 20s with an uneventful pre-natal course and a spontaneous vaginal delivery at 37w2d. Two weeks after delivery, she experienced symptoms of heart failure and was found to have a new diagnosis of HFrEF. At that time TTE showed LVEF 30-35%, LVIDd 5.1cm (top normal size), diffuse hypokinesis. At that time, she was diuresed and discharged on metoprolol succinate 25mg po daily and furosemide 20mg po daily. She had one follow up visit 6 months postpartum and the furosemide was discontinued. Today in your office, she has NYHA Class I symptoms with no signs of symptoms of congestion. She walks daily and does vigorous exercise 1-2 times per week, while remaining on metoprolol. Repeat TTE with LVEF 45-50% and similar LV size. She would like to have another child and was referred to you for counseling.
Case 1 Rounding Pearls:
Dr. Walsh discussed extensively the importance of full GDMT in this patient who was initially undertreated with only a beta blocker. If patients are breastfeeding, clinicians should consider the addition of ACE-Inhibitor and Spironolactone. Otherwise, if not breastfeeding, they should receive maximally tolerated doses of full GDMT. For more details on medical therapy for Heart Failure during pregnancy and after, refer to this previous CardioNerds Episode with Dr. Julie Damp.
Patients with peripartum cardiomyopathy are at highest risk of worsening LV systolic function when they have persistent LV systolic dysfunction from their initial diagnosis. In this circumstance, shared decision making is paramount. These patients should receive counseling on contraception and risk of pregnancy on worsening LV function, death, & fetal demise. In addition, counseling includes discussing with patients limited options in some states for complete, comprehensive reproductive care, including pregnancy termination.
If patients with prior peripartum cardiomyopathy do become pregnant, a team-based approach including cardiologists, maternal fetal medicine, and obstetrics (amongst other team members) is essential to determine care & delivery timing/method. These patients should also be examined for signs of decompensation throughout the pregnancy, including rales, S3 or a reported history of PND.
282. Guidelines: 2021 ESC Cardiovascular Prevention – Question #20 with Dr. Michael Wesley Milks
Apr 05, 2023
The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by Brigham & Women’s medicine intern & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Michael Wesley Milks.
Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology's Cardiovascular Disease Prevention Leadership Council.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #20
Ms. Ruma Toid is a 65-year-old African American woman who presents to your clinic in Ohio for routine follow up. She has a history of rheumatoid arthritis, hypertension, obesity, and sleep apnea. Her medications include methotrexate and atenolol. Her blood pressure in the office is 120/80 mmHg, heart rate 68 bpm, and oxygen saturation 99% on room air. Recent lipid testing revealed total cholesterol 165 mg/dL, HDL 42 mg/dL, and LDL 118 mg/dL. She was recently advised to talk to her doctor about taking a statin due to her risk factors but in the past has heard negative things about those medications and would like your advice on next steps. Her calculated ASCVD risk score based on the Pooled Cohort Equation is 7%. Which of the following choices would be the next step?AShe is at borderline risk for ASCVD events. A statin is not indicated at this time.BDue to her history of rheumatoid arthritis, her calculated ASCVD risk should be multiplied by 1.5, yielding an ASCVD risk of 10.5% placing her in the intermediate risk category. Moderate intensity statin would be indicated.CWhen other risk factors are present, rheumatoid arthritis is no longer an enhancing risk factor.DStatins are contraindicated when taking methotrexate.
Answer #20
ExplanationThe correct answer is B. Due to her history of rheumatoid arthritis, her calculated ASCVD risk should be multiplied by 1.5, yielding an ASCVD risk of 10.5% placing her in the intermediate risk category. Moderate intensity statin would be indicated. Due to her history of rheumatoid arthritis, her calculated ASCVD risk should be multiplied by 1.5, yielding an ASCVD risk of 10.5% placing her in the intermediate risk category. Moderate intensity statin would be indicated. The ESC gives a Class IIa (LOE B) indication to multiply the calculated total CVD risk by a factor of 1.5 in adults with rheumatoid arthritis due to the observed 50% increased CVD risk in patients with rheumatoid arthritis. This 50% increase in CVD risk attributed to RA is present beyond traditional risk factors, making answer choice C wrong. Answer A is incorrect because when borderline risk is calculated, one should still look for risk enhancers that could potentially increase ASCVD risk before final determination of statin indication. Answer choice D is false as there is no contraindication to take both methotrexate and statins together. Note that it is appropriate to use the pool cohort equations and American risk thresholds for this patient since she is in America where the PCE was validated (versus using SCORE2 risk model which would be more appropriate for European populations).Main TakeawayInflammatory conditions including rheumatoid arthritis and inflammatory bowel disease increase a person’s risk for ASCVD events. Specifically for rheumatoid arthritis, there is a Class IIa indication to multiply the calculated risk score by 1.5 to account for rheumatoid arthritis as a risk enhancer.
281. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #14 with Dr. Javed Butler
Apr 04, 2023
The following question refers to Section 9.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Duke University cardiology fellow and CardioNerds FIT Ambassador Dr. Aman Kansal, and then by expert faculty Dr. Javed Butler.
Dr. Butler is an advanced heart failure and transplant cardiologist, President of the Baylor Scott and White Research Institute, Senior Vice President for the Baylor Scott and White Health, and Distinguished Professor of Medicine at the University of Mississippi.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #14
Mrs. Hart is a 70-year-old woman hospitalized for a 2-week course of progressive exertional dyspnea, increasing peripheral edema, and mental status changes. She has a history of coronary artery disease, hypertension, and heart failure for which she takes aspirin, furosemide, carvedilol, lisinopril, and spironolactone. On physical exam, the patient is afebrile, BP is 80/60 mmHg, heart rate is 120 bpm, and respiratory rate is 28 breaths/min with O2 saturation of 92% breathing room air. She is sitting upright and is confused. Jugular venous pulsations are elevated. Cardiac exam reveals an S3 gallop. There is ascites and significant flank edema on abdominal exam. Her lower extremities have 2+ pitting edema to her knees and are cool to touch. Her labs are significant for an elevated serum Creatinine of 3.0 from a baseline of 1.0 mg/dL, lactate of 3.0 mmol/L, and liver enzyme elevation in the 300s U/L.
Which of the following is the most appropriate initial treatment?
A
Increase carvedilol
B
Start dobutamine
C
Increase lisinopril
D
Start nitroprusside
Answer #14
Explanation
The Correct answer is B – start dobutamine.
This patient with progressive congestive symptoms, mental status changes, and signs of hypoperfusion and end-organ dysfunction meets the clinical criteria of cardiogenic shock. The Class 1 recommendation is that in patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and maintain end-organ performance (LOE B-NR). Their broad availability, ease of administration, and clinician familiarity favor such agents as first line when signs of hypoperfusion persist. Interestingly, despite their ubiquitous use for management of cardiogenic shock, there is a lack of robust evidence to suggest the clear benefit of one agent over another. Therefore, the choice of a specific agent is guided by additional factors including vital signs, concurrent arrhythmias, and availability. For this patient, dobutamine is the only inotrope listed. Although she is tachycardic, her lack of arrhythmia makes dobutamine relatively lower risk and does not outweigh the potential benefits.
Choice A – Increase carvedilol – is not correct. Beta-blockers should be continued in HF hospitalization whenever possible; however, in a patient with low cardiac output and signs of shock, beta-blockers should be discontinued due to their negative inotropic effects.
Choice C – Increase lisinopril – is not correct. Afterload reduction is reasonable to decrease myocardial oxygen demand. However, given the hypotension and renal dysfunction, increasing lisinopril could be potentially dangerous by fur...
280. CCC: Sedation in the Cardiac ICU with Dr. Christopher Domenico
Apr 02, 2023
The practice of critical care cardiology relies on the use of invasive hemodynamics, mechanical ventilation, mechanical circulatory support, and other advanced techniques to help our patients recover from critical cardiac illnesses. To facilitate these interventions, it is essential to have a broad understanding of how sedation and analgesia keep our patients comfortable and safe throughout their time in the CICU. In this episode, series co-chair, Dr. Yoav Karpenshif, and CardioNerds co-founder, Dr. Daniel Ambinder, are joined by Dr. Natalie Tapaskar, cardiology fellow and CardioNerds FIT Ambassador from Stanford, and faculty expert, Dr. Chris Domenico, to discuss sedation in the cardiac ICU. Notes were drafted by Dr. Natalie Tapaskar. Audio editing by CardioNerds academy intern, Anusha Gandhi.
We discuss the use of analgesics and sedative medications in the cardiac ICU. We dissect three cases of VT storm, heart failure associated cardiogenic shock, and cardiac arrest. We assess the hemodynamic, arrhythmic, and metabolic effects of opioids and sedatives and delve into the altered pharmacokinetics of these drugs during targeted temperature management. Most importantly, we highlight the use of structured pain and sedation scoring systems and discuss the recognition and management of ICU delirium both from a pharmacologic and non-pharmacologic standpoint.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Sedation in the Cardiac ICU with Dr. Christopher Domenico
Think about analgesia and sedation as separate entities with management of analgesia first and sedation second. Frequent re-assessment of needs should be performed to reduce ICU delirium and improve long-term outcomes.
Fentanyl is generally a good starting point for analgesia in the ICU since it is fast on/fast off, but can stick around for a long time the longer it is used. The choice of bolus or continuous infusion opioids depends on the clinical scenario and personal/institutional preference. Remember to administer bolus doses that are 50-100% of the hourly continuous infusion dose to reach steady state faster.
When managing refractory VT storm with sedative agents (propofol, benzodiazepines and/or dexmedetomidine), you should target the deepest level of sedation necessary to suppress sympathetic drive.
For cardiogenic shock patients, the choice of sedative agent is a nuanced decision. Think about etomidate first for intubation as it has the least cardiovascular and hemodynamic impact. And remember the propofol trifecta: negative inotropy, direct vasodilation, and bradycardia!
Pharmacokinetics are disrupted during targeted temperature management, thus be weary of overly sedating patients due to reduced drug clearance.
Show notes - Sedation in the Cardiac ICU with Dr. Christopher Domenico
How do we initiate analgesics and sedatives?
Analgesia first and sedation second!
Analgesia: think about how to reduce a patient’s painEveryone has a different pain tolerance and critically ill patients can have moderate to severe pain at baseline.
Metrics to assess pain include self-reported scales, behavioral scales, facial expressions, extremity movement, compliance with the ventilator, tachycardia, tachypnea, and hypertension.
Sedation: think about how to reduce a patient’s agitation or anxietyThe target depth of sedation depends on the clinical scenario.For example,
279. Guidelines: 2021 ESC Cardiovascular Prevention – Question #19 with Dr. Eugene Yang
Mar 29, 2023
The following question refers to Section 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern, student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.
Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #19
True or False: A 70-year-old male has an estimated 10-year ASCVD risk (using SCORE2-OP) of 7.5% which confers a very high CVD risk and necessitates treatment with a statin.
TRUE
FALSE
Answer #19
Explanation
FALSE – CVD risk thresholds for risk factor treatment are higher in apparently healthy people 70 years and older in order to prevent overtreatment in the elderly. A 10-year CVD risk ≥15% is considered “very high risk” for individuals ≥70 years of age (compared to a ≥7.5% cut-off for “very high risk” in younger patients <50 years old). For these patients, treatment of ASCVD risk factors, including lipid-lowering medications, is recommended (class IIb). Lifetime benefit of treatment in terms of time gained free of CVD is lower in older people. The SCORE2-OP algorithm estimates 5-year and 10-year fatal and non-fatal CVD events adjusted for competing risks of non-CVD mortality. Treatment and risk stratification should (as with all patients) be individualized.
For patient >70 years of age, a 10-year CVD risk of 7.5 to <15% is considered “high risk”, and treatment of risk factors should be considered taking CVD risk modifiers, frailty, lifetime treatment benefit, comorbidities, polypharmacy, and patient preference into account.
For patient >70 years of age, a 10-year CVD risk of <7.5 is considered “low-to-moderate risk” and would generally not qualify for risk factor treatment unless one or several risk modifiers are present.
Smoking cessation, lifestyle recommendations and a SBP <160 mmHg are recommended for all.
Main Takeaway
CVD risk assessment for patients 70-years and older is estimated using the SCORE2-OP algorithm. A predicted 10-year CVD risk score of ≥15% confers a very high CVD risk, however, this it is a class IIb indication to initiate/intensify lipid lowering therapies in these patients. Decision should be individualized and based on benefits vs risk assessment.
Guideline Loc.
3.2.3.5
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278. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #13 with Dr. Anu Lala
Mar 29, 2023
The following question refers to Section 9.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Duke University cardiology fellow and CardioNerds FIT Ambassador Dr. Aman Kansal, and then by expert faculty Dr. Anu Lala.
Dr. Lala is an advanced heart failure and transplant cardiologist, associate professor of medicine and population health science and policy, Director of Heart Failure Research, and Program Director for the Advanced Heart Failure and Transplant fellowship training program at Mount Sinai. Dr. Lala is deputy editor for the Journal of Cardiac Failure. Dr. Lala has been a champion and role model for CardioNerds. She has been a PI mentor for the CardioNerds Clinical Trials Network and continues to serve in the program’s leadership. She is also a faculty mentor for this very 2022 heart failure decipher the guidelines series.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #13
Mrs. Hart is a 63-year-old woman with a history of non-ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 20-25%) presenting with 5 days of worsening dyspnea and orthopnea. She takes carvedilol 12.5mg BID, sacubitril-valsartan 24-46mg BID, empagliflozin 10mg daily, and furosemide 40mg daily and reports that she has been able to take all her medications. What is the initial management for Mrs. H?
A
Assess her degree of congestion and hypoperfusion
B
Search for precipitating factors
C
Evaluate her overall trajectory
D
All of the above
E
None of the above
Answer #13
Explanation
The correct answer is D – all of the above.
Choice A is correct because in patients hospitalized with heart failure, the severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy (Class 1, LOE C-LD). Congestion can be assessed by using the clinical exam to gauge right and left-sided filling pressures (e.g., elevated JVP, S3, edema) which are usually proportional in decompensation of chronic HF with low EF; however, up to 1 in 4 patients have a mismatch between right- and left-sided filling pressures. Hypoperfusion can be suspected from narrow pulse pressure and cool extremities, intolerance to neurohormonal antagonists, worsening renal function, altered mental status, and/or an elevated serum lactate. For more on the bedside evaluation of heart failure, enjoy Episode #142 – The Role of the Clinical Examination in Patients With Heart Failure – with Dr. Mark Drazner.
Choice B, searching for precipitating factors is also correct. In patients hospitalized with HF, the common precipitating factors and the overall patient trajectory should be assessed to guide appropriate therapy (Class 1, LOE C-LD). Common precipitating factors include ischemic and nonischemic causes, such as acute coronary syndromes, atrial fibrillation and other arrhythmias, uncontrolled HTN, other cardiac disease (e.g., endocarditis), acute infections, anemia, thyroid dysfunction, non-adherence to medications or new medications. When initial clinical assessment does not suggest congestion or hypoperfusion, symptoms of HF may be a result of transient ischemia, arrhythmias, or noncardiac disease such as chronic pulmonary disease or pneumonia,
277. Case Report: When Infarction Brings the Walls Down – Brigham and Women’s Hospital
Mar 28, 2023
CardioNerds (Amit and Dan) join Dr. Maria Pabon (cardiology fellow), Dr. Kevin Bersell (cardiology fellow), Dr. Saad Sultan Ghumman (interventional cardiology fellow), and Dr. Rhanderson Cardoso (cardiovascular imaging fellow) from Brigham and Women’s Hospital. Together, they explore a complex case of STEMI that was further complicated by ventricular free wall rupture. Additionally, Dr. Ajar Kochar, Program Director for Interventional Cardiology at Brigham and Women's Hospital, provides an insightful "ECPR" segment, adding a unique perspective to the case. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This is the case of a patient who presented with STEMI and was found to have a moderate pericardial effusion with echogenic material within the pericardial space concerning for thrombus. Urgent CTA/CT surgery was engaged due to concern for dissection, but no evidence of dissection, rupture or intramural hematoma was found. The patient underwent an urgent pericardiocentesis which yielded 350cc of hemorrhagic fluid, leading to an improvement in hemodynamic status. A coronary angiogram was performed which showed a 100% thrombotic occlusion of OM 1, the culprit lesion for the STEMI. Due to the possibility of a delayed STEMI and high suspicion for mechanical complication of MI, aspirin and IV cangrelor were chosen as the preferred antiplatelet strategy. However, cangrelor was held and cardiac surgery was consulted, as LV free wall rupture was suspected. The patient underwent urgent repair of the LV free wall rupture, with an uneventful post-op recovery and discharge on day 8 to cardiac rehab.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Media
Pearls - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
In the era of primary PCI, mechanical complications of MI are relatively rare.
Timely recognition using multi-modality imaging and prompt surgical intervention can result in favorable outcomes.
An approach that involves a Heart Team can be advantageous in optimizing outcomes in such complex cases.
Show Notes - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
Incidence of post AMI LV free wall rupture:
0.1-1%
Risk factors for LV Free wall Rupture:
Older age
Female sex
Prior HTN
1st lateral or Anterior Wall MI
Protective factors towards free wall rupture:
LV hypertrophy
CHF
Hx of prior infarcts
Chronic ischemic heart disease
Early use of beta blockers post MI
Timely intervention
Incidence of Mortality associated with mechanical rupture related to AMI:
8-10%
When to suspect a mechanical complication of AMI:
AMI with shock/hypotension
New murmur
New pericardial effusion > 10mm on bedside echo
Other etiologies that can cause free wall rupture:
Trauma
Cardiac infection
Aortic dissection
Cardiac tumors
Infiltrative diseases
Iatrogenic from PCI or surgical procedures
References - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
Varghese S, Ohlow MA. Left ventricular free wall rupture in myocardial infarction: A retrospective analysis from a single tertiary center. JRSM Cardiovasc Dis. 2019 Jan-Dec;8:2048004019896692. doi: 10.1177/2048004019896692. PMID: 31970072.
Pineda-De Paz, D.O.,
276. Left Ventricular Assist Devices and Renal Dysfunction with Dr. Brian Houston and Dr. Nisha Bansal
Mar 22, 2023
CardioNerds (Dr. Amit Goyal), Dr. Sonu Abraham (CardioNerds Ambassador from Lahey Hospital and Medical Center, Burlington, MA) discuss left ventricular assist devices (LVAD) and the implications of renal dysfunction with Dr. Brian Houston and Dr. Nisha Bansal. This episode will focus on the intersection of left ventricular assist devices and renal dysfunction. Patients with a combination of heart failure and renal dysfunction overall have a guarded prognosis and their management poses unique challenges to the clinician. We initially discuss the basics of an LVAD and general approach to LVAD candidacy evaluation. We then discuss specific implications of acute kidney injury, presence of preexisting CKD, and end stage renal disease in patients with/being considered for an LVAD. Risk factor identification and prognostication allows for appropriate selection of the right candidates for an LVAD in the context of renal disease. Dr. Brian Houston is the Director of the Mechanical Circulatory Support program at Medical University of South Carolina. Dr. Nisha Bansal is an Associate Professor and the Arthur Stach Family Endowed Professor in the Division of Nephrology, an investigator at the Kidney Research Institute, the Director of Nephrology Clinical and Research Education, and the Director of the Kidney-Heart Service at the University of Washington. Notes were drafted by Dr. Sonu Abraham and episode audio was edited by student Dr. Chelsea Amo-Tweneboah.
Check out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content!
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Pearls - Left Ventricular Assist Devices and Renal Dysfunction
End stage renal disease (CKD on dialysis) is considered an absolute contraindication for LVAD implantation. Select young patients who are being considered for heart-kidney transplantation in the near future may be candidates for an LVAD as a bridge to heart-kidney transplantation.
LVAD implantation can improve kidney function in the short term in patients with AKI primarily caused by cardio-renal syndrome.
Patients with pre-existing CKD (not dialysis dependent) have a greater risk of developing AKI after LVAD implantation.
Several dialysis modalities including in-center hemodialysis, home hemodialysis, and peritoneal dialysis are available for LVAD patients. However, there are several challenges associated with each modality.
An AV graft is a useful vascular access option in LVAD patients undergoing hemodialysis due to a lower risk of infection and ease of immediate use.
Causes for anemia in patients with an LVAD and renal dysfunction include anemia of chronic disease, gastrointestinal bleeding, and pump thrombosis leading to hemolysis.
Show notes - Left Ventricular Assist Devices and Renal Dysfunction
Notes: (drafted by Dr. Sonu Abraham)
What is a left ventricular assist device (LVAD) and what are its components?
An LVAD supports circulation by unloading the left ventricle and providing increased cardiac output to help support organ perfusion. Use in properly selected patients is associated with improved quality of life and increased survival. The current iteration of LVADs offer continuous flow, as opposed to the older versions which employed pulsatile flow.
Components of the LVAD:
Inflow cannula (sucks blood from the LV)
Pump
Outflow cannula (dumps blood into the aorta)
Percutaneous driveline
Electrical controller
How is a patient evaluated for LVAD candidacy?
The 2 main questions to be answered during the evaluation of a patient for an LVAD are:
1. Are they sick enough? Do they have end stage heart failure?
2. Do we expect the benefits of an LVAD to outweigh the risks?
...
275. Case Report: A Rare Cause Of Fatigue, Dyspnea, And Weight Loss In An Elderly Man – Brigham and Women’s Hospital
Mar 20, 2023
CardioNerds (Amit and Dan) join Dr. Khaled Abdelrahman, Dr. Gurleen Kaur, and Dr. Danny Pipilas from the Brigham and Women’s Hospital Residency Program for Italian food and cannolis at the North End in Boston as they discuss the case of an elderly man with primary cardiac lymphoma. They review an approach to intracardiac masses, discuss advantages and disadvantages of various imaging modalities for the evaluation of intracardiac masses, and also delve into anthracycline toxicity. The E-CPR segment is provided by Dr. Ron Blankstein, Associate Director of the Cardiovascular Imaging Program and Director of Cardiac Computed Tomography at Brigham and Women’s Hospital. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
A 76-year-old man with a history of hyperlipidemia presented with one month of progressively worsening fatigue, weight loss, and dyspnea on exertion. Physical exam was notable for a 3/6 systolic murmur at the left upper sternal border, a flopping sound along the sternum heard throughout the cardiac cycle, and JVP elevated to the level of the mandible. TTE revealed a large heterogeneous echodensity in the right ventricular (RV) free wall that extended into the pericardium and into the RV myocardium with mobile components in the RV cavity and obstruction of the RV outflow tract. Nongated CT chest showed a solid nodule in the periphery of the left lower lung lobe. Gated cardiac CTA revealed a large heterogenous mass in the right atrioventricular groove that encased the proximal thoracic aorta and pulmonary artery and invaded the RV myocardium and RV outflow tract along with a large pericardial effusion. On cardiac MRI, the mass was isointense to the myocardium on T1-weighted images, hyperintense on T2-weighted images, and had heterogenous enhancement on late gadolinium enhancement images. Overall, the imaging findings were highly suspicious for cardiac lymphoma which was confirmed with biopsy of the lung nodule; pathology showed a large B cell lymphoma. The patient was treated with R-CHOP therapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), and TTE after 6 cycles of chemotherapy demonstrated resolution of the RV mass.
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Case Media
1. There is a large homogeneous mass in the right atrioventricular groove that extends anterior to the right ventricular outflow tract, pulmonary artery, and ascending aorta, measuring up to 9.4 x 7.1 cm (axial) x 13 cm (craniocaudal). The mass encases the proximal thoracic aorta and pulmonary artery. The mass invades the right ventricular myocardium, the right ventricular outflow tract, the pulmonary artery, and proximal main pulmonary artery. There is severe stenosis of the right ventricular outflow tract due to obstruction by the mass. The mass encases the right coronary artery, without compression of the artery. There is enhancement of this mass on delayed contrast imaging. Collectively, these findings suggest cardiac lymphoma. 2. There is a large pericardial effusion, circumferential, measuring up to 2.2 cm adjacent to the right atrium and up to 2.3 cm anterior to the intraventricular septum. There is pericardial enhancement, indicative of pericardial inflammation. 3. This study was not optimized for the assessment of the coronary arteries. However,
274. Cardio-Oncology: Cancer Therapy-Related Cardiac Dysfunction (CTRCD) – The Cardiologist Perspective with Dr. Joerg Hermann
Mar 16, 2023
CardioNerds co-founder Amit Goyal, Dr. Dinu Balanescu, Dr. Teodora Donisan, and Dr. Anjali Agarwalla get the cardiologist perspective of Cancer Therapy-Related Cardiac Dysfunction (CTRCD) from Dr. Joerg Hermann. We previously learned from the oncologist perspective with Dr. Susan Dent in Episode #261! In this episode, we discuss the history of cancer therapies and our developing understanding of how these life-saving medications can cause cardiac toxicities. As we manage patients in the CardioNerds CardioOncology clinic, we ask Dr. Hermann how the general cardiologist should approach patients with a cancer diagnosis, when should a patient be referred to a cardiooncology specialist, and what are the common cardiotoxicities to look out for. We’ll also place a quick consult to our guest expert’s goldendoodle! Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Cancer Therapy-Related Cardiac Dysfunction (CTRCD) – The Cardiologist Perspective with Dr. Joerg Hermann
Patients with malignancy will incur several “hits” in addition to their malignancy and its subsequent treatment — these include their genetics, environment, and comorbidities. The role of the cardiologist is to identify how the combination of these “hits” can bring cardiovascular disease to the forefront and where we can intervene upon it.
The sooner we recognize cardiotoxicity, the better the outcome for our patients. Patients should receive baseline risk assessment with TTE and biomarkers with routine surveillance.
You cannot assign a percentage to cardiac risk in cancer. Patients require a multidisciplinary approach with constant monitoring and surveillance.
Consider exercise testing when conducting pre-treatment risk assessment and during monitoring. Peak VO2 abnormalities is often the first marker of cardiotoxicity — though note that it correlates well with global longitudinal strain (GLS).
If someone develops a cardiovascular complication of chemotherapy, this should prompt referral to cardiooncology.
Show notes - Cancer Therapy-Related Cardiac Dysfunction (CTRCD) – The Cardiologist Perspective with Dr. Joerg Hermann
What types of cardiovascular pathology occur in the setting of cancer and its treatment?
We conventionally thought of cardiotoxicities as being of two types:
Type 1: irreversible cardiac injury that does not improve despite withdrawal of offending chemotherapeutic (protype = classic anthracycline cardiotoxicity)
Type 2: reversible cardiac dysfunction that improves with discontinuation of chemotherapeutic (prototype = classic traztuzumab cardiotoxicity)
However, we have begun moving away from this thought process as it has become more evident that injuries historically thought of as “type 1” may not be as relentless as previously understood, and that patients with type 2 dysfunction may not actually be returning to completely normal after the offending agent is withdrawn. As such, this episode proposes two other ways to frame our understanding of cardiotoxicities: a clinical/practical approach, based on symptoms (symptomatic vs asymptomatic — this is the approach used by the ESC guidelines), and a mechanistic approach: direct effect on cardiac myocytes, indirect effects (e.g., effect on coronaries), and inflammatory effects.
273. Digital Health: The Digital Transformation of Cardiovascular Medicine with Dr. Dipti Itchhaporia
Mar 14, 2023
Join CardioNerds Co-Founder Dr. Dan Ambinder, Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital and Johns Hopkins Bayview) and student Dr. Shivani Reddy (Medical Student at Western Michigan University Homer Stryker SOM), as they discuss how digital health in changing the landscape of CV Disease Management with Dr. Dipti Itchhaporia (Past President of the ACC). The overall goal of this episode is to broadly describe the current landscape of digital health for cardiovascular disease, define “digital health tools” and describe their role in cardiovascular disease management. Episode audio was edited by student Dr. Shivani Reddy and show notes were developed by Dr. Nino Isakadze.
In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients.
This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
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Pearls and Quotes
COVID 19 pandemic accelerated the digital transformation of healthcare.
Digital health tools exist for disease prediction, diagnosis and management.
Digital health can increase access to care and lower overall cost expenditure.
Clinicians, policy makers, and insurance providers should be involved to facilitate rapid and effective adoption of digital health interventions to better patient and population health.
Notes
1. How did the COVID-19 pandemic accelerate the process of adopting digital health tools in healthcare including cardiovascular disease management?
Although technological advances and technological transformation have been implemented in many aspects of our lives, their adoption in healthcare, including cardiovascular disease management has lagged behind.
The COVID-19 pandemic was a force that led to the Tech-celeration as we adopted telemedicine and remote patient monitoring platforms in a short time to preserve access to healthcare.
Technology became essential not to replace but to support face to face interactions.
Reimbursement models were rapidly created that fit digital healthcare delivery; however it remains unclear whether these models will continue to be in effect in the post pandemic era.
2. Can you discuss broadly the current landscape of evidence-based digital health tools available for cardiovascular disease management?
Three components of digital health landscape can be broken down as follows:Virtual care/telehealth platformsRemote patient monitoring systems including implanted devices, patches, wearables, smartphone applications and more
Artificial intelligence to allow meaningful use of the big data obtained from remote patient monitoring systems in therapeutic and disease management pathways
3.
272. CardioNerds Rounds: Challenging Cases – Hemodynamics and Mechanical Circulatory Support with Dr. Daniel Burkhoff
Mar 12, 2023
It’s another session of CardioNerds Rounds! In these rounds, Dr. Karan Desai (Formerly FIT at University of Maryland Medical Center and currently faculty at Johns Hopkins School of Medicine) joins Dr. Dan Burkhoff (Director of Heart Failure, Hemodynamics and MCS Research at the Cardiovascular Research Foundation) to discuss mechanical circulatory support options through the lens of pressure-volume loops! Dr. Burkhoff is the author of Harvi, an interactive simulation-based application for teaching and researching many aspects of ventricular hemodynamics. Don’t miss this wonderfully nerdy episode with a world-renowned expert in hemodynamics and MCS! Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
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Show notes - Hemodynamics and Mechanical Circulatory Support
Case Synopsis:
Case SynopsisWe focused on one case during these rounds. A man in his mid-50s presented to his local community hospital with 3 days of chest pain, nausea, and vomiting. He appeared ill in the emergency room with HR in the 150s, BP 90/70s and ECG demonstrating inferior ST elevations. He was taken emergently to the catheterization lab and received overlapping stents to his right coronary artery. Over the next 24 hours, he developed a new harsh systolic murmur heard throughout his precordium and progressed to cardiogenic shock. Echocardiogram demonstrated a large basal inferoseptum ventricular septal rupture. From this point, we discussed the hemodynamics of VSR and MCS options.
Case Takeaways
Dr. Burkhoff took us through the hemodynamics of VSR with pressure-volume loops to better understand the pathology and impact of various MCS options. Of note, there are no MCS devices specifically approved to treat acute ventricular septal rupture.
In regards to the acute hemodynamic effects of a VSR (an abrupt left to right shunt), there are several aspects to note. First, the effective LV afterload is reduced; however, there is less “forward flow” as well and as a consequence, decreased left-sided cardiac output (“Qs”) and blood pressure. At the same time, flow through the pulmonary artery increases (the “Qp”). Additionally, due to the abrupt shunt flow, there is increased RV “loading” with increasing central venous pressure and pulmonary artery pressure.
The hemodynamic priorities in treating patients with cardiogenic shock and VSR are to normalize blood pressure, cardiac output, and oxygen delivery, while attempting to minimize shunt flow to allow healing. However, medications and MCS are unlikely to completely normalize hemodynamics. For instance, if the patient was placed on peripheral VA ECMO, while total CO and BP may increase, flow across the VSR could also increase at high ECMO flows (e.g., by introducing more LV afterload).
In patients with persistent cardiogenic shock and VSR, short-term MCS to divert flow away from the shunt can be an effective strategy. LV-to-aorta or LA-to-arterial MCS may provide the best single-device hemodynamic profiles by decreasing shunt flow, reducing pulmonary capillary wedge pressure, and improving blood pressure.
Surgical and percutaneous VSD repair are the definitive treatment options. If able to stabilize patients and pursue delayed repair,
271. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #12 with Dr. Shashank Sinha
Mar 08, 2023
The following question refers to Section 9.5 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by Brigham & Women’s medicine resident and Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Shashank Sinha.
Dr. Sinha is an Assistant Professor of Medical Education at the University of Virginia School of Medicine and an advanced heart failure, MCS, and transplant cardiologist at Inova Fairfax Medical Campus. He currently serves as both the Director of the Cardiac Intensive Care Unit and Cardiovascular Critical Care Research Program at Inova Fairfax. He is also a Steering Committee member for the multicenter Cardiogenic Shock Working Group and Critical Care Cardiology Trials Network and an Associate Editor for the Journal of Cardiac Failure, the official Journal of the Heart Failure Society of America.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #12
Mr. Shock is a 65-year-old man with a history of hypertension and non-ischemic cardiomyopathy (LVEF 25%) who is admitted with acute decompensated heart failure. He is currently being diuresed with a bumetanide drip, but is only making 20 cc/hour of urine. On exam, blood pressure is 85/68 mmHg and heart rate is 110 bpm. His JVP is at 12 cm and extremities are cool with thready pulses. Bloodwork is notable for a lactate of 3.5 mmol/L and creatinine of 2.5 mg/dL (baseline Cr 1.2 mg/dL). What is the most appropriate next step?
A
Augment diuresis with metolazone
B
Start sodium nitroprusside
C
Start dobutamine
D
Start oral metoprolol
E
None of the above
Answer #12
Explanation
The correct answer is C – start dobutamine.
In this scenario, the patient is in cardiogenic shock given hypotension and evidence of end-organ hypoperfusion on exam and labs. The patient’s cool extremities, low urine output, elevated lactate, and elevated creatinine all point towards hypoperfusion.
In patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and preserve end-organ function (Class 1, LOE B-NR). Further, in patients with cardiogenic shock whose end-organ function cannot be maintained by pharmacologic means, temporary MCS is reasonable to support cardiac function (Class 2a, LOE B-NR).
The SCAI Cardiogenic Shock Criteria can be used to divide patients into stages. Stage A is a patient at risk for cardiogenic shock but currently not with any signs or symptoms, for example, a patient presenting with a myocardial infarction without present evidence of shock. Stage B is “pre-shock” – this may be a patient who has volume overload, tachycardia, and hypotension but does not have hypoperfusion based on exam and lab evaluation. Stage C is classic cardiogenic shock – the cold and wet profile. Bedside findings for Stage C shock include cool extremities, weak pulses, altered mental status, decreased urine output, and/or respiratory distress. Lab findings include impaired renal function, increased lactate, increased hepatic enzymes, and/or acidosis. Stage D is deteriorating with worsening hypotension and hypoperfusion with escalating use of pressors or mechanical circulatory support.
270. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #11 with Dr. Prateeti Khazanie
Mar 07, 2023
The following question refers to Section 8.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Western Michigan University medical student & CardioNerds Intern Shivani Reddy, answered first by Brigham & Women’s medicine resident and Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Prateeti Khazanie.
Dr. Khazanie is an Associate Professor and Advanced Heart Failure and Transplant Cardiologist at the University of Colorado. She was an undergraduate at Duke University as a B.N. Duke Scholar. She spent two years at the NIH in the lab of Dr. Anthony Fauci and completed a dual MD-MPH program at Duke Medical School. When she started residency, she thought she was going to be an ID doctor, but she fell in love with cardiology at Stanford where she was an intern, resident, and then chief resident. She went back to Duke for her general cardiology and advanced heart failure/transplant fellowships as well as research training at the DCRI. Dr. Khazanie joined the University of Colorado in 2015 as a health services clinician researcher with a focus on improving health equity and bioethics in advanced heart failure care. She mentors medical students, residents, and fellows and is a faculty mentor for the University of Colorado Cardiology Fellows “House of Cards” mentoring group. She has research funding from the NIH/NHLBI K23, NIH Ethics Grant, and Ludeman Center for Women’s Health Research. Dr. Khazanie is an author on the 2022 ACC/AHA/HFSA HF Guidelines, the 2021 HFSA Universal Definition of Heart Failure, and multiple scientific statements.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #11
A 64-year-old woman with a history of chronic systolic heart failure secondary to NICM (LVEF 15-20%) s/p dual chamber ICD presents for routine follow-up. She reports several months of progressive fatigue, dyspnea, and peripheral edema. She has been hospitalized twice in the past year with acute decompensated heart failure. Efforts to optimize guideline directed medical therapy have been tempered by episodes of lightheadedness and hypotension. Her exam is notable for an elevated JVP, an S3 heart sound, and a III/VI holosystolic murmur best heard at the apex with radiation to the axilla. Labs show Na 130 mmol/L, Cr 1.8 mg/dL (from 1.1 mg/dL 6 months prior), and NT-proBNP 1,200 pg/mL. ECG in clinic shows sinus rhythm and a nonspecific IVCD with QRS 116 ms. Her most recent TTE shows biventricular dilation with LVEF 15-20%, moderate functional MR, moderate functional TR and estimated RVSP of 40mmHg. What is the most appropriate next step in management?
A
Refer to electrophysiology for upgrade to CRT-D
B
Increase sacubitril-valsartan dose
C
Refer for advanced therapies evaluation
D
Start treatment with milrinone infusion
Answer #11
Explanation
The correct answer is C – refer for advanced therapies evaluation.
Our patient has multiple signs and symptoms of advanced heart failure including NYHA Class III-IV functional status, persistently elevated natriuretic peptides, severely reduced LVEF, evidence of end organ dysfunction, multiple hospitalizations for ADHF, edema despite escalating doses of diuretics, and progressive intolerance to GDMT. Importantly, the 2018 European Society of Cardiology revised definition of advanced HF focuses...
269. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #10 with Dr. Michelle Kittleson
Feb 28, 2023
The following question refers to Section 7.7 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by St. George's University medical student and CardioNerds Intern Chelsea Tweneboah, answered first by Baylor College of Medicine Cardiology Fellow and CardioNerds Ambassador Dr. Jamal Mahar, and then by expert faculty Dr. Michelle Kittleson.Dr. Kittleson is Director of Education in Heart Failure and Transplantation, Director of Heart Failure Research, and Professor of Medicine at the Smidt Heart Institute, Cedars-Sinai. She is Deputy Editor of the Journal of Heart and Lung Transplantation, on Guideline Writing Committees for the American College of Cardiology (ACC)/American Heart Association, is the Co Editor-in-Chief for the ACC Heart Failure Self-Assessment Program, and on the Board of Directors for the Heart Failure Society of America. Her Clinician’s Guide to the 2022 Heart Failure guidelines, published in the Journal of Cardiac Failure, are a must-read for everyone!The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #10
Ms. Heffpefner is a 54-year-old woman who comes to your office for a routine visit. She does report increased fatigue and dyspnea on exertion without new orthopnea or extremity edema. She was previously diagnosed with type 2 diabetes, morbid obesity, obstructive sleep apnea, and TIA. She is currently prescribed metformin 1000mg twice daily, aspirin 81mg daily, rosuvastatin 40mg nightly, and furosemide 40mg daily. In clinic, her BP is 140/85 mmHg, HR is 110/min (rhythm irregularly irregular, found to be atrial fibrillation on ECG), and BMI is 43 kg/m2. Transthoracic echo shows an LVEF of 60%, moderate LV hypertrophy, moderate LA enlargement, and grade 2 diastolic dysfunction with no significant valvulopathy. What is the best next step?
A
Provide reassurance
B
Refer for gastric bypass
C
Refer for atrial fibrillation ablation
D
Start metoprolol and apixaban
Answer #10
ExplanationThe correct answer is D – start metoprolol and apixaban.Ms. Hefpeffner has a new diagnosis of atrial fibrillation (AF) and has a significantly elevated risk for embolic stroke based on her CHA2DS2-VASc score of 6 (hypertension, diabetes, heart failure, prior TIA, and female sex). The relationship between AF and HF is complex and the presence of either worsens the status of the other. Managing AF in patients with HFpEF can lead to symptom improvement (Class 2a, LOR C-EO). However, large, randomized trial data are unavailable to specifically guide therapy in patients with AF and HFpEF. Generally, management of AF involves stroke prevention, rate and/or rhythm control, and lifestyle / risk-factor modification. With regards to stroke prevention, patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women) should receive chronic anticoagulant therapy (Class 1, LOE A). When anticoagulation is used in chronic HF patients with AF, a DOAC is recommended over warfarin in eligible patients (Class 1, LOE A).The decision for rate versus rhythm control should be individualized and reflects both patient symptoms and the likelihood of better ventricular function with sinus rhythm. For patients with HF and symptoms caused by AF,
268. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #9 with Dr. Nancy Sweitzer
Feb 22, 2023
The following question refers to Section 7.6 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by premedical student and CardioNerds Intern Pacey Wetstein, answered first by Baylor College of Medicine Cardiology Fellow and CardioNerds Ambassador Dr. Jamal Mahar, and then by expert faculty Dr. Nancy Sweitzer.
Dr. Sweitzer is Professor of Medicine, Vice Chair of Clinical Research for the Department of Medicine, and Director of Clinical Research for the Division of Cardiology at Washington University School of Medicine. She is the editor-in-chief of Circulation: Heart Failure. Dr. Sweitzer is a faculty mentor for this Decipher the HF Guidelines series.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #9
Mr. Flo Zin is a 64-year-old man who comes to discuss persistent lower extremity edema and dyspnea with mild exertion. He takes amlodipine for hypertension but has no other known comorbidities. In the clinic, his heart rate is 52 bpm and blood pressure is 120/70 mmHg. Physical exam reveals mildly elevated jugular venous pulsations and 1+ bilateral lower extremity edema. Labs show an unremarkable CBC, normal renal function and electrolytes, a Hb A1c of 6.1%, and an NT-proBNP of 750 (no prior baseline available). On echocardiogram, his LVEF is 44% and nuclear stress testing was negative for inducible ischemia. What is the best next step in management?
A
Add furosemide BID and daily metolazone
B
Start empagliflozin and furosemide as needed
C
Start metoprolol succinate
D
No change to medical therapy
Answer #9
Explanation
The correct answer is B – start empagliflozin and furosemide as needed.
The patient described here has heart failure with mildly reduced EF (HFmrEF), given LVEF in the range of 41-49%.
In patients with HF who have fluid retention, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF (Class 1, LOE B-NR). For patients with HF and congestive symptoms, addition of a thiazide (eg, metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate or high-dose loop diuretics to minimize electrolyte abnormalities (Class 1, LOE B-NR). Therefore, option A is not correct as he is only mildly congested on examination, and likely would not require such aggressive decongestive therapy, particularly with normal renal function. Adding a thiazide diuretic without first optimizing loop diuretic dosing would be premature.
The EMPEROR-Preserved trial showed a significant benefit of the SGLT2i, empagliflozin, in patients with symptomatic HF, with LVEF >40% and elevated natriuretic peptides. The 21% reduction in the primary composite endpoint of time to HF hospitalization or cardiovascular death was driven mostly by a significant 29% reduction in time to HF hospitalization, with no benefit on all-cause mortality. Empagliflozin also resulted in a significant reduction in total HF hospitalizations, decrease in the slope of the eGFR decline, and a modest improvement in QOL at 52 weeks. Of note, the benefit was similar irrespective of the presence or absence of diabetes at baseline. In a subgroup of 1983 patients with LVEF 41% to 49% in EMPEROR-Preserved, empagliflozin, an SGLT2i, reduced the risk of the primary composite endpoint of cardiovascular death or hospitalization f...
267. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #8 with Dr. Gregg Fonarow
Feb 21, 2023
The following question refers to Section 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Palisades Medical Center medicine resident & CardioNerds Intern Dr. Maryam Barkhordarian, answered first by MedStar Washington Hospital Center cardiology hospitalist & CardioNerds Academy Graduate Dr. Luis Calderon, and then by expert faculty Dr. Gregg Fonarow.Dr. Fonarow is the Professor of Medicine and Interim Chief of UCLA's Division of Cardiology, Director of the Ahmanson-UCLA Cardiomyopathy Center, and Co-director of UCLA's Preventative Cardiology Program.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #8
Ms. Flo Zinn is a 60-year-old woman seen in cardiology clinic for follow up of her chronic HFrEF management. She has a history of stable coronary artery disease, hypertension, hypothyroidism, and recurrent urinary tract infections. She does not have a history of diabetes and recent hemoglobin A1c is 5.0%. Her current medications include carvedilol, sacubitril-valsartan, eplerenone, and atorvastatin. Her friend was recently placed on an SGLT2 inhibitor and asks if she should be considered for one as well. Which of the following is the most important consideration when deciding to start this patient on an SGLT2 inhibitor?
A
The patient does not have a history of type 2 diabetes and so does not qualify for SGLT2 inhibitor therapy
B
While SGLT2 inhibitors improve hospitalization rates for HFrEF, there is no evidence that they improve cardiovascular mortality
C
Patients taking SGLT2 inhibitors tend to suffer a more rapid decline in renal function than patients not taking SGLT2 inhibitor therapy
D
Patients may be at a higher risk for genitourinary infections if an SGLT2 inhibitor is started
Answer #8
Explanation
The correct answer is D – SGLT2 inhibitors have been associated with increased risk of genitourinary infections.
Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors have gathered a lot of press recently as the new kid on the block with respect to heart failure management. While they were initially developed as antihyperglycemic medications for treating diabetes, early cardiovascular outcomes trials showed reduced rates of heart failure hospitalization amongst study participants independent of glucose-lowering effects and irrespective of baseline heart failure status – only 10-14% of patients carried a heart failure diagnosis at baseline. This prompted trials to study the effects of SGLT2 inhibitors in patients with symptomatic chronic HFrEF who were already on guideline directed medical therapy irrespective of the presence of type 2 diabetes mellitus. The DAPA-HF and EMPEROR-Reduced trials showed that dapagliflozin and empagliflozin, respectively, both conferred statistically significant improvements in a composite of heart failure hospitalizations and cardiovascular death (Option B). Most interestingly, these effects were seen irrespective of diabetes history. In light of these findings, the 2022 HF guidelines recommend SGLT2 inhibitors in patients with chronic, symptomatic HFrEF with or without diabetes to reduce hospitalization for HF and cardiovascular mortality (Class I, LOE A).
The benefits of SGLT2 inhibitors extend beyond cardiovascular health.
266. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #7 with Dr. Robert Mentz
Feb 15, 2023
The following question refers to Section 7.3.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.
The question is asked by Palisades Medical Center medicine resident & CardioNerds Intern Dr. Maryam Barkhordarian, answered first by MedStar Washington Hospital Center cardiology hospitalist & CardioNerds Academy Graduate Dr. Luis Calderon, and then by expert faculty Dr. Robert Mentz.
Dr. Mentz is associate professor of medicine and section chief for Heart Failure at Duke University, a clinical researcher at the Duke Clinical Research Institute, and editor-in-chief of the Journal of Cardiac Failure. Dr. Mentz is a mentor for the CardioNerds Clinical Trials Network as lead principal investigator for PARAGLIDE-HF and is a series mentor for this very 2022 heart failure Decipher the Guidelines Series. For these reasons and many more, he was awarded the Master CardioNerd Award during ACC22. Welcome Dr. Mentz!
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #7
Ms. Valarie Sartan is a 55-year-old woman with a history of HFrEF (EF 35%) and well controlled, non-insulin dependent diabetes mellitus who presents to heart failure clinic for routine follow up. She is currently being treated with metoprolol succinate 200mg daily, lisinopril 10mg daily, empagliflozin 10mg daily, and spironolactone 50mg daily. She notes stable dyspnea with moderate exertion, making it difficult to do her yardwork. On exam she is well appearing, and blood pressure is 115/70 mmHg with normal jugular venous pulsations and trace bilateral lower extremity edema. On labs, her potassium is 4.0 mmol/L and creatinine is 0.7 mg/dL with an eGFR > 60 mL/min/1.73m2. Which of the following options would be the most appropriate next step in heart failure therapy?
A
Increase lisinopril to 40mg daily
B
Increase spironolactone to 100mg daily
C
Add sacubitril-valsartan to her regimen
D
Discontinue lisinopril and start sacubitril-valsartan in 36 hours
E
No change
Answer #7
Explanation
The correct answer is D – transitioning from an ACEi to an ARNi is the most appropriate next step in management.
The renin-angiotensin aldosterone system (RAAS) is upregulated in patients with chronic heart failure with reduced ejection fraction (HFrEF). Blockade of the RAAS system with ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), or angiotensin receptor neprilysin inhibitors (ARNi) have proven mortality benefit in these patients.
The PARADIGM-HF trial compared sacubitril-valsartan (an ARNi) with enalapril in symptomatic patients with HFrEF. Patients receiving ARNi incurred a 20% relative risk reduction in the composite primary endpoint of cardiovascular death or heart failure hospitalization. Based on these results, the 2022 heart failure guidelines recommend replacing an ACEi or ARB for an ARNi in patients with chronic symptomatic HFrEF with NYHA class II or III symptoms to further reduce morbidity and mortality (Option D). This is a class I recommendation with level of evidence of B-R and is also of high economic value. Making no changes at this time would be inappropriate (Option E).
While it would be reasonable to increase the dose of lisinopril to 40mg (Option A), this should be pursued only if ARNi therapy is not tolerated.
Mineralocorticoid receptor antagonists (MRAs) have a class I (LOE A...
265. Case Report: An Unusual Case of Non-ischemic Cardiomyopathy – Cleveland Clinic
Feb 15, 2023
CardioNerds co-founder Daniel Ambinder joins Cleveland Clinic cardiology fellows, Dr. Essa Hariri, Dr. Anna Scandinaro, and Dr. Beka Bekhdatze, Clinical pharmacist at Cleveland Clinic, Dr. Ashley Kasper, and Dr. Craig Parris from Ohio State University Medical Center for a walk at Edgewater Park in Cleveland, Ohio. Dr. Andrew Higgins (Crtitical Care Cardiology and Advanced HF / Transplant Cardiology at Cleveland Clinic) provides the ECPR for this episode. They discuss the following case involving a rare cause of non-ischemic cardiomyopathy. A young African American male was admitted for cardiogenic shock following an admission a month earlier for treatment resistant psychosis. He was diagnosed with medication-induced non-ischemic cardiomyopathy, which resolved with a remarkable recovery of his systolic function after discontinuation of the culprit medication, Clozapine. Episode notes were drafted by Dr. Essa Hariri. Audio editing by CardioNerds Academy Intern, student doctor Shivani Reddy.
Enjoy this case report co-published in US Cardiology Review: Clozapine-induced Cardiomyopathy: A Case Report
CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).
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Pearls - An Unusual Case of Non-ischemic Cardiomyopathy
The diagnosis of drug-induced non-ischemic cardiomyopathy is usually one of exclusion. High clinical suspicion is needed to diagnose drug-induced cardiomyopathy.
Missing the culprit medication causing drug-induced cardiomyopathy could be detrimental as there is a high probability of reversing a systolic dysfunction after stopping the offending medication.
Clozapine is an effective medication for the treatment-resistant schizophrenia and is associated with reduced suicide risk.
Clozapine is reported to cause drug-induced cardiomyopathy and is more common with rapid drug titration. Clozapine is more commonly associated with myocarditis.
Close monitoring and vigilance are critical to preventing cardiac complications associated with initiating clozapine.
The management of clozapine-associated cardiomyopathy includes clozapine cessation and heart failure guideline-directed medical therapy.
Show Notes - An Unusual Case of Non-ischemic Cardiomyopathy
We treated a case of clozapine-associated cardiomyopathy presenting in cardiogenic shock. Drug-induced cardiomyopathy is a common yet under-recognized etiology of non-ischemic cardiomyopathy. Clozapine is an FDA-approved atypical antipsychotic medication frequently prescribed for treatment-resistant schizophrenia and the only antipsychotic agent that has been proven to significantly reduce suicide among this patient population.
However, Clozapine is reported to be associated with several forms of cardiotoxicity, including myocarditis (most common), subclinical clozapine associated cardiotoxicity, and least commonly, drug-induced cardiomyopathy. Clozapine-associated cardiomyopathy should be considered as a differential diagnosis in schizophrenic patients presenting with signs of acute heart failure.
Rapid titration of clozapine is a risk factor for clozapine-associated cardiomyopathy and clozapine-associated myocarditis. To date, there is no evidence or consensus supporting preemptive screening. According to the American Psychiatric Association, whenever clozapine-induced myocarditis or cardiomyopathy is suspected, a cardiology consult is warranted.
264. CCC: Approach to Renal Replacement Therapy in the CICU with Dr. Joel Topf
Feb 12, 2023
Renal replacement therapy (RRT) is routinely utilized in the CICU. Series co-chairs Dr. Eunice Dugan and Dr Karan Desai along with CardioNerds Co-founder Dr. Daniel Ambinder were joined by FIT lead and CardioNerds Ambassador from University of Washington, Dr. Tomio Tran. Our episode expert is world-renowned nephrologist Dr. Joel Topf. Dr. Topf is Medical Director of Research at St. Clair Nephrology, and editor of the Handbook of Critical Care Nephrology. In this episode, we describe a case of cardiogenic shock due to acute myocardial infarction resulting in renal failure, ultimately requiring continuous RRT (CRRT). We discuss the most common causes of AKI within the cardiac ICU, indications for initiating RRT, evidence on the timing of RRT, different modes of RRT, basic management of the RRT circuit, and how to transition patients off of RRT during renal recovery. Episode notes were drafted by Dr. Tomio Tran. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Approach to Renal Replacement Therapy in the CICU
Do not commit “Renalism” - withholding lifesaving treatments from patients with renal impairment due to fear of causing renal injury. Shared decision making is key.
In the ICU, most of the time, AKI is caused by ATN due to adverse hemodynamics. Nephrologists can help determine the cause if the patient has an atypical presentation.
Late dialysis initiation is non-inferior to early dialysis initiation. Early initiation may lead to higher rates of prolonged time on dialysis.
Slow low efficiency daily diafiltration (SLEDD) vs CRRT are equivalent in terms of outcomes and are the preferred methods among patients with hypotension. Intermittent Hemodialysis (iHD) can be used once patients are hemodynamically stable.
A “Furosemide Stress Test” can be used to test intact renal function or renal recovery by challenging the nephron to make urine.
Show notes - Approach to Renal Replacement Therapy in the CICU
What are the risk factors and differential for AKI in the CICU?
Start by using the pre-renal vs intrinsic renal vs post-renal framework. Additional considerations in cardiac patients include contrast induced nephropathy, pigment nephropathy, cardiorenal syndrome. Enjoy Episode 262. Management of Cardiorenal Syndrome in the CICU.
In the ICU setting, intrinsic renal injury due to ATN is among the most common etiology of AKI.
Many risk factors for AKI are not modifiable in the ICU. Optimize renal function by avoiding nephrotoxins, minimizing contrast usage, and keeping the MAP >65-75 mmHg.
Contrast nephropathy as an etiology is questionable and may be a marker of a sicker patient population. Avoid “Renalism” - providing substandard care to patients with renal disease due to fear of worsening renal function.
Most etiologies are treated with supportive care.
What is the approach to timing of renal replacement therapy initiation?
Definitions for early vs late vs very late initiation of RRT:Early – Worsening AKI without indications for RRTLate – Worsening AKI with relative indications for RRT
Very late – Worsening AKI with strict indications for RRT
Late initiation is noninferior in terms of mortality; early initiation is associated with higher rates of prolonged/permanent RRT.1,2,3
Very late initiation associated with worse outcomes.4 In general,
263. ACHD: Patent Ductus Arteriosus & Eisenmenger Syndrome with Dr. Candice Silversides
Feb 10, 2023
Join CardioNerds to learn about patent ducts arteriosus and Eisenmenger syndrome! Dr. Dan Ambinder (CardioNerds co-founder), ACHD series co-chair Dr. Dan Clark, Dr. Tony Pastor (ACHD fellow, Harvard Medical School), and Dr. Kate Wilcox, Medicine/Pediatrics Resident, Medical College of Wisconsin join Dr. Candice Silversides (Editor-in-chief #JACCAdvances) for this terrific discussion. Notes were drafted by Dr. Kate Wilcox. .Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
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Pearls - Patent Ductus Arteriosus & Eisenmenger Syndrome
The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass the high resistance pulmonary circuit present in utero.
After birth there is a significant drop in pulmonary vascular resistance (PVR) which generally leads to functional ductal closure within 48 hours (permanent seal takes 2-3 weeks to form).
Risk factors for having a PDA include birth before 37 weeks of gestation, trisomy 21, and congenital rubella.
A PDA results in a left to right shunt (qP:qS >1) which over time overloads the left side of the heart and causes pulmonary vascular remodeling. The extra workload on the left side of the heart causes left atrial (can cause atrial arrhythmias) and left ventricular dilation.
If left untreated you can eventually have shunt reversal due to very high PVR (Eisenmenger physiology). There are some treatment options at this point (pulmonary vasodilators, etc) but it’s definitely better to close the PDA before this point.
One interesting physical exam finding that can stem from shunt reversal in a hemodynamically significant PDA is differential cyanosis (upper body or pre-ductal saturations will be higher than lower body/post-ductal saturations). You can also see clubbing in the toes but not the hands for the same reason.
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The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information.
262. CCC: Management of Cardiorenal Syndrome in the CICU with Dr. Nayan Arora and Dr. Elliott Miller
Feb 06, 2023
The Cardiorenal Syndrome is commonly encountered, and frequently misunderstood. Join the CardioNerds team as we discuss the complex interplay between the heart and kidneys with Dr. Elliott Miller (Assistant Professor of Medicine at Yale University School of Medicine and Associate Medical Director of the Cardiac Intensive Care Unit of Yale New Haven Hospital), and Dr. Nayan Arora (Clinical Assistant Professor of Medicine and Nephrologist at the University of Washington Medical Center). We are hosted by FIT lead Dr. Matthew Delfiner (Cardiology Fellow at Temple University), Cardiac Critical Care Series Co-Chairs Dr. Mark Belkin (AHFTC faculty at University of Chicago) and Dr. Karan Desai (Cardiologist at Johns Hopkins Hospital), and CardioNerds Co-Found Dr. Dan Ambinder. In this episode we discuss the definition and pathophysiology of the cardiorenal syndrome, explore strategies for initial diuresis and diuretic resistance, and management of the common heart failure medications in this setting. Show notes were developed by Dr. Matthew Delfiner. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Management of Cardiorenal Syndrome in the CICU
Cardiorenal syndrome (CRS) represents a range of clinical entities in which there is both heart and kidney dysfunction, and can be driven by one, or both, of the organs.
CRS is caused by reduced renal perfusion, elevated renal congestion, or a combination of the two. Treatment therefore focuses on increasing perfusion, by optimizing cardiac output and mean arterial pressure, and reducing congestion through diuresis.
Patients should be monitored for an adequate response to the initial diuretic dose within 2 hours of administration. If the response is inadequate, the loop diuretic dose should be doubled.
Diuretic resistance can be managed via sequential nephron blockade, most commonly with thiazide diuretics, but also with amiloride, high-dose spironolactone, or acetazolamide, as these target different regions of the nephron.
In cases of refractory diuretic resistance, hypertonic saline can be considered with the help of an experienced clinician.
Continuation or cessation of renin-angiotensin-aldosterone system (RAAS) inhibitors in the setting of CRS should be made on a case-by-case basis.
Show notes - Management of Cardiorenal Syndrome in the CICU
1. Cardiorenal syndrome (CRS) is a collection of signs/symptoms that indicate injury to both the heart and kidneys. Organ dysfunction in one can drive dysfunction in the other. Cardiorenal syndrome can be categorized as:
Type 1 - Acute heart failure causing acute kidney injury
Type 2 - Chronic heart failure causing chronic kidney injury
Type 3 - Acute kidney injury causing acute heart failure
Type 4 - Chronic kidney injury causing chronic heart failure
Type 5 - Co-development of heart and kidney injury by another systemic process.
These categories can be helpful for education, discussion, and research purposes, but they do not usually enter clinical practice on a regular basis since different categories of cardiorenal syndrome are not necessarily treated differently.
2. CRS is caused by either reduced renal perfusion, elevated renal congestion, or a combination of the two. When dealing with CRS, note that:
CRS can be caused by poor kidney perfusion,
261. Cardio-Oncology: Cancer Therapy-Related Cardiac Dysfunction (CTRCD) – The Oncologist Perspective with Dr. Susan Dent
Jan 31, 2023
Dr. Filip Ionescu (hematology-oncology fellow at Moffitt Cancer Center in Tampa, FL), Dr. Teodora Donisan (cardiology fellow at the Mayo Clinic in Rochester, MN and CardioNerds House Thomas chief), Dr. Sarah Waliany (internal medicine chief resident at Stanford University in Palo Alto, CA), Dr. Dinu Balanescu (internal medicine chief resident at Beaumont Hospital in Royal Oak, MI) and Dr. Amit Goyal (structural interventional cardiology fellow at the Cleveland Clinic, in Cleveland, OH and CardioNerds Co-Founder), discuss the cardiotoxicities of common cancer treatments with Dr. Susan Dent, a medical oncologist and one of the founders of the field of Cardio-Oncology. Using the recently published ESC Guidelines on cardio-oncology, they cover cardiovascular risk stratification in oncology patients, pretreatment testing, as well as prevention and management of established cardiotoxicity resulting from anthracyclines, trastuzumab, and fluoropyrimidines. They touch on the unique aspects of cardio-oncology encountered in patients with breast cancer, rectal cancer, and lung cancer, who are frequently the recipients of multiple cardiotoxic treatments. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
Access the CardioNerds Cardiac Amyloidosis Series for a deep dive into this important topic.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Cancer Therapy-Related Cardiac Dysfunction (CTRCD) – The Oncologist Perspective with Dr. Susan Dent
Formal cardiovascular risk stratification must be performed prior to initiating a potentially cardiotoxic anticancer treatment regimen. Considering both drug toxicity and patient-related factors (e.g., age, smoking, hypertension etc) is important.
Anthracyclines affect the cardiomyocyte in complex ways which lead to a largely irreversible cardiomyopathy. All patients should have a pretreatment echocardiogram and ECG.
Trastuzumab cardiotoxicity, by contrast, is more like stunning the myocardium, which manifests as a reversible decrease in left ventricular ejection fraction which generally normalizes upon discontinuation of the drug.
The treatment of chemotherapy-induced cardiomyopathy should involve interdisciplinary discussions and shared decision making with the patient. Beyond guideline-directed medical therapy of heart failure with reduced ejection fraction, management can include temporarily holding or permanently discontinuing the offending agent.
Fluoropyrimidine-associated cardiotoxicity manifests as cardiac ischemia from coronary vasospasm. A 5FU infusion is essentially a stress test as it tends to unmask clinically silent atherosclerosis.
Show notes
What is the basic pretreatment assessment of any oncology patient who is to receive a potentially cardiotoxic regimen?
Awareness and management of the cardiovascular toxicity of oncology treatments are of paramount importance to be able to deliver treatment safely and to achieve maximal efficacy guided by an expert multidisciplinary team. Thanks to Dr. Dent and her colleagues’ work, this year we have seen the publication of the first Cardio-Oncology guideline (1). Perhaps the most important recommendation is that cancer patients about to start a cardiotoxic regimen should undergo formal cardiovascular risk stratification by considering both the adverse profile of the planned treatment...
260. Case Report: Cardioembolic Stroke from an Unusual Valve Pathology from The University of Alabama at Birmingham
Jan 22, 2023
CardioNerds Cofounder Dr. Amit Goyal join Dr. Usman Hasnie and Dr. Will Morgan from University of Alabama at Birmingham for a hike up Red Mountain. They discuss the following case: A 75-year-old woman with prior mitral valve ring annuloplasty presented with subacute, intermittent, self-limiting neurologic deficits. Brain MRI revealed multiple subacute embolic events consistent with cardioembolic phenomena. Transesophageal echochardiogram discovered a mobile mass on the mitral valve as the likely cause for cardioembolic stroke. She was taken for surgical repair of the mitral valve. Tissue biopsy confirmed that the mass was an IgG4-related pseudotumor. Expert commentary is provided by Dr. Neal Miller (Assistant Professor of Cardiology, University of Alabama at Birmingham). Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares
Check out this published case report here: IgG4-Related Disease Masquerading as Culture-Negative Endocarditis!
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Pearls - Cardioembolic Stroke due to an IgG4-related pseudotumor
Surgical indications for endocarditis include severe heart failure, valvular dysfunction with severe hemodynamic compromise, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis (in infective endocarditis) despite adequate antibiotic therapy.
IgG4 related disease is rare, and likely underrecognized due to the lack of reliable biomarkers. Biopsy and histologic confirmation are imperative to clinch the diagnosis.
Cardiac manifestations of IgG4-related disease are rare but are often related to aortopathies. Valvular disease is extremely rare as a manifestation of the disease.
Treatment of IgG4 related disease includes steroids as the first line treatment.
IgG4 related disease requires a multi-disciplinary approach to both diagnose and treat.
Show Notes - Cardioembolic Stroke due to an IgG4-related pseudotumor
Notes were drafted by Dr. Hasnie and Dr. Morgan
IgG4-related disease has a very diverse presentation including mimicry of infection, malignancy and other autoimmune conditions. It is a fibroinflammatory condition that results in deposition of IgG4 positive plasma cells. It has been described in multiple organ systems including the pancreas, kidneys, lungs and salivary glands.
Cardiac manifestations are extremely rare and valvular disease even more so. There are thirteen cases of IgG4 related valvular disease, and of these only two had mitral valve involvement such as this case. The most commonly reported cardiovascular manifestations are related to aortopathies.
This disease remains poorly understood at this point. There are no true biomarkers that can be used to risk stratify the diagnosis for clinicians. Biopsy is imperative to the diagnosis. Even serum IgG4 levels are normal in 30% of cases despite meeting histologic criteria on biopsy making the diagnosis incredibly difficult to make.
While guidelines have not been developed to guide treatment of IgG4-related disease, steroids are considered the first line treatment option for patients. Often times dosing is 2-4 weeks with a prolonged taper. When looking for glucocorticoid sparing agents, azathioprine, mycophenolate mofetil, and methotrexate are considered alternatives.
References - Cardioembolic Stroke due to an IgG4-related pseudotumor
1. Kamisawa T, Funata N, Hayashi Y, et al. A new clinicopathological entity of IgG4- related autoimmune disease. J Gastroenterol 2003;38:982-4.
2. Deshpande V, Zen Y, Chan JK, et al. Consensus statement on the pathology of IgG4-related disease. Mod Pathol. 2012;25(9):1181-1192. doi:10.1038/modpathol.2012.72
3. Dahlgren M,
259. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #6 with Dr. Randall Starling
Jan 20, 2023
The following question refers to Section 7.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Cornell cardiology fellow and CardioNerds Ambassador Dr. Jaya Kanduri, and then by expert faculty Dr. Randall Starling.Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #6
Mr. D is a 50-year-old man who presented two months ago with palpations and new onset bilateral lower extremity swelling. Review of systems was negative for prior syncope. On transthoracic echocardiogram, he had an LVEF of 40% with moderate RV dilation and dysfunction. EKG showed inverted T-waves and low-amplitude signals just after the QRS in leads V1-V3. Ambulatory monitor revealed several episodes non-sustained ventricular tachycardia with a LBBB morphology.
He was initiated on GDMT and underwent genetic testing that revealed 2 desmosomal gene variants associated with arrhythmogenic right ventricular cardiomyopathy (ARVC).
Is the following statement true or false?
“ICD implantation is inappropriate at this time because his LVEF is >35%”
True
False
Answer #6
Explanation
This statement is False. ICD implantation is reasonable to decrease sudden death in patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death who have an LVEF ≤45% (Class 2a, LOE B-NR).
While the HF guidelines do not define high-risk features of sudden death, the 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy identify major and minor risk factors for ventricular arrhythmias as follows:
Major criteria: NSVT, inducibility of VT during EPS, LVEF ≤ 49%.
Minor criteria: male sex, >1000 premature ventricular contractions (PVCs)/24 hours, RV dysfunction, proband status, 2 or more desmosomal variants.
According to the HRS statement, high risk is defined as having either three major, two major and two minor, or one major and four minor risk factors for a class 2a recommendation for primary prevention ICD in this population (LOE B-NR).
Based on these criteria, our patient has 2 major risk factors (NSVT & LVEF ≤ 49%), and 3 minor risk factors (male sex, RV dysfunction, and 2 desmosomal variants) for ventricular arrhythmias. Therefore, ICD implantation for primary prevention of sudden cardiac death is reasonable.
Decisions around ICD implantation for primary prevention remain challenging and depend on estimated risk for SCD, co-morbidities, and patient preferences, and so should be guided by shared decision making weighing the possible benefits against the risks,
258. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #5 with Dr. Clyde Yancy
Jan 20, 2023
The following question refers to Section 7.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Cornell cardiology fellow and CardioNerds Ambassador Dr. Jaya Kanduri, and then by expert faculty Dr. Clyde Yancy.Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the AHA/ACC/HFSA Heart Failure Guideline Writing Committee.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #5
Ms. L is a 65-year-old woman with nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 35%, hypertension, and type 2 diabetes mellitus. She has been admitted to the hospital with decompensated heart failure (HF) twice in the last six months and admits that she struggles to understand how to take her medications and adjust her sodium intake to prevent this. Which of the following interventions has the potential to decrease the risk of rehospitalization and/or improve mortality?
A
Access to a multidisciplinary team (physicians, nurses, pharmacists, social workers, care managers, etc) to assist with management of her HF
B
Engaging in a mobile app aimed at improving HF self-care
C
Vaccination against respiratory illnesses
D
A & C
Answer #5
The correct answer is D – both A (access to a multidisciplinary team) and C (vaccination against respiratory illness).
Choice A is correct. Multidisciplinary teams involving physicians, nurses, pharmacists, social workers, care managers, dieticians, and others, have been shown in multiple RCTs, metanalyses, and Cochrane reviews to both reduce hospital admissions and all-cause mortality. As such, it is a class I recommendation (LOE A) that patients with HF should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival.
Choice B is incorrect. Self-care in HF comprises treatment adherence and health maintenance behaviors. Patients with HF should learn to take medications as prescribed, restrict sodium intake, stay physically active, and get vaccinations. They also should understand how to monitor for signs and symptoms of worsening HF, and what to do in response to symptoms when they occur. Interventions focused on improving the self-care of HF patients significantly reduce hospitalizations and all-cause mortality as well as improve quality of life. Therefore, patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner (Class I, LOE B-R). However, the method of delivery and education matters. Reinforcement with structured telephone support has been shown to be effective. In contrast the efficacy of mobile health-delivered educational interventions in improve self-care in patients with HF remains uncertain.
Choice C is correct. In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality (Class 2a, LOE B-NR). For example, administration of the influenza vaccine in HF patients has been shown to reduce...
257. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #4 with Dr. Eldrin Lewis
Jan 15, 2023
The following question refers to Section 4.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Baylor University cardiology fellow and CardioNerds FIT Trialist Dr. Shiva Patlolla, and then by expert faculty Dr. Eldrin Lewis.
Dr. Lewis is an Advanced Heart Failure and Transplant Cardiologist, Professor of Medicine and Chief of the Division of Cardiovascular Medicine at Stanford University.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #4
Mr. Stevens is a 55-year-old man who presents with progressively worsening dyspnea on exertion for the past 2 weeks. He has associated paroxysmal nocturnal dyspnea, intermittent exertional chest pressure, and bilateral lower extremity edema. Otherwise, Mr. Stevens does not have any medical history and does not take any medications.
Which of the following will be helpful for diagnosis at this time?
A
Detailed history and physical examination
B
Chest x-ray
C
Blood workup including CBC, CMP, NT proBNP
D
12-lead ECG
E
All of the above
Answer #4
The correct answer is E – All of the above.
Mr. Stevens presents with signs and symptoms of volume overload concerning for new onset heart failure. The history and physical exam remain the cornerstone in the assessment of patients with HF. Not only is the H&P valuable for identifying the presence of heart failure but also may provide hints about the degree of congestion, underlying etiology, and alternative diagnoses. As such H&P earns a Class 1 indication for a variety of reasons in patients with heart failure:
1. Vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications (Class 1, LOE B-NR)
2. Clinical factors indicating the presence of advanced HF should be sought via the history and physical examination (Class 1, LOE B-NR)
3. A 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease (Class 1, LOE B-NR)
4. A thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management (Class 1, LOE B-NR)
5. A thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF (Class 1, LOE C-EO)
Building on the H&P, laboratory evaluation provides important information about comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, severity and prognosis of HF, and more. As such, for patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management (Class 1, LOE C-EO). In addition, the specific cause of HF should be explored using additional laboratory testi...
256. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #3 with Dr. Shelley Zieroth
Jan 13, 2023
The following question refers to Section 3.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Rochester General Hospital cardiology fellow and Director of CardioNerds Journal Club Dr. Devesh Rai, and then by expert faculty Dr. Shelley Zieroth.
Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She is a steering committee member for PARAGLIE-HF and a PI Mentor for the CardioNerds Clinical Trials Program.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #3
Which of the following is/are true about heart failure epidemiology?
A
Although the absolute number of patients with HF has partly grown, the incidence of HF has decreased
B
Non-Hispanic Black patients have the highest death rate per capita resulting from HF
C
In patients with established HF, non-Hispanic Black patients have a higher HF hospitalization rate compared with non-Hispanic White patients
D
In patients with established HF, non-Hispanic Black patients have a lower death rate compared with non-Hispanic White patients
E
All of the above
Answer #3
Explanation
The correct answer is “E – all of the above.”
Although the absolute number of patients with HF has partly grown as a result of the increasing number of older adults, the incidence of HF has decreased. There is decreasing incidence of HFrEF and increasing incidence of HFpEF. The health and socioeconomic burden of HF is growing. Beginning in 2012, the age-adjusted death-rate per capita for HF increased for the first time in the US. HF hospitalizations have also been increasing in the US. In 2017, there were 1.2 million HF hospitalizations in the US among 924,000 patients with HF, a 26% increase compared with 2013.
Non-Hispanic Black patients have the highest death rate per capita. A report examining the US population found the age-adjusted mortality rate for HF to be 92 per 100,000 individuals for non-Hispanic Black patients, 87 per 100,000 for non-Hispanic White patients, and 53 per 100,000 for Hispanic patients.
Among patients with established HF, non-Hispanic Black patients experienced a higher rate of HF hospitalization and a lower rate of death than non-Hispanic White patients with HF.Hispanic patients with HF have been found to have similar or higher HF hospitalization rates and similar or lower mortality rates compared with non-Hispanic White patients.
Asian/Pacific Islander patients with HF have had a similar rate of hospitalization as non-Hispanic White patients but a lower death rate.
These racial and ethnic disparities warrant studies and health policy changes to address health inequity.
Main Takeaway
Racial and ethnic disparities in death resulting from HF persist, with non-Hispanic Black patients having the highest death rate per capita, and a higher rate of HF hospitalization. Further clinical studies and health policy changes are needed to address ...
255. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #2 with Dr. Mark Drazner
Jan 10, 2023
The following question refers to Section 6.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Mount Sinai Hospital cardiology fellow and CardioNerds FIT Trialist Dr. Jason Feinman, and then by expert faculty Dr. Mark Drazner.
Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the President of the Heart Failure Society of America.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #2
A 67-year-old man with a past medical history of type 2 diabetes mellitus, hypertension, and active tobacco smoking presents to the emergency room with substernal chest pain for the past 5 hours. An electrocardiogram reveals ST segment elevations in the anterior precordial leads and he is transferred emergently to the catheterization laboratory. Coronary angiography reveals 100% occlusion of the proximal left anterior descending artery, and he is successfully treated with a drug eluting stent resulting in TIMI 3 coronary flow. Following his procedure, a transthoracic echocardiogram is performed which reveals a left ventricular ejection fraction of 35% with a hypokinetic anterior wall. Which of the following medications would be the best choice to prevent the incidence of heart failure and reduce mortality?
A
Lisinopril
B
Diltiazem
C
Carvedilol
D
Sacubitril-valsartan
E
Both A and C
Answer #2
The correct answer is E – both lisinopril and carvedilol are appropriate to reduce the incidence of heart failure and mortality.
Evidence-based beta-blockers and ACE inhibitors both have Class 1 recommendations in patients with a recent myocardial infarction and left ventricular ejection fraction ≤ 40% to reduce the incidence of heart failure and to reduce mortality. Multiple randomized controlled trials have investigated both medications in the post myocardial infarction setting and demonstrated improved ventricular remodeling as well as benefits for mortality and development of incident heart failure.
At this time, there is not sufficient evidence to recommend ARNi over ACEi for patients with reduced LVEF following acute MI. The PARADISE-MI trial randomized a total of 5,661 patients with myocardial infarction complicated by a reduced LVEF, pulmonary congestion, or both to receive either sacubitril-valsartan (97-103mg twice daily) or ramipril (5mg twice daily). After a median follow up time of 22 months, there was no statistically significant difference in the primary outcome of cardiovascular death or incident heart failure. At this time, ARNi have not been included in the guidelines for this specific population.
Diltiazem is a non-dihydropyridine calcium channel blocker, a family of drugs with negative inotropic effects and which may be harmful in patients with depressed LVEF (Class 3: Harm, LOE C-LD).
Main Takeaway:
For patients with recent myocardial infarction and reduced left ventricular function both beta blockers and ACEi have Class 1 recommendations to reduce the incidence of heart failure and decrease mortality.
Guideline Location:
Section 6.1
254. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #1 with Dr. Biykem Bozkurt
Jan 09, 2023
The following question refers to Section 2.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Mount Sinai Hospital cardiology fellow and CardioNerds FIT Trialist Dr. Jason Feinman, and then by expert faculty Dr. Biykem Bozkurt.
Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines.
The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
Question #1
A 23-year-old man presents to his primary care physician for an annual visit. His father was diagnosed with idiopathic cardiomyopathy at 40 years of age. His blood pressure in clinic is 146/90 mmHg. He is a personal trainer and exercises daily, including both weightlifting and cardio. He denies any anabolic steroid use. He is an active tobacco smoker, approximately ½ pack per day. Review of systems is negative for symptoms. What stage of heart failure most appropriately describes his current status?
A
Stage A
B
Stage B
C
Stage C
D
Stage D
E
None of the above
Answer #1
The correct answer is A – Stage A of heart failure.
Overall, the ACC/AHA stages of HF were designed to emphasize the development and progression of disease. More advanced stages and progression are associated with reduced survival.
Stage A HF is where patients are “at risk for HF”, but without current or previous symptoms or signs of HF, and without structural/functional heart disease or abnormal biomarkers. At-risk patients include those with hypertension, cardiovascular disease, diabetes, obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or family history of cardiomyopathy.
Stage B HF is the “pre-heart failure” stage where patients are without current or previous symptoms or signs of HF but do have at least one of the following:
Structural heart disease (i.e., reduced left or right ventricular systolic function, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, and valvular heart disease)
Evidence of increased filling pressures
Risk factors and increased natriuretic peptide levels or persistently elevated cardiac troponin in the absence of an alternate diagnosis
Stage C HF indicates symptomatic heart failure where patients have current or previous symptoms or signs of HF.
Stage D HF indicates advanced heart failure with marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy.
Therapeutic interventions in each stage aim to modify risk factors (Stage A), treat risk and structural heart disease to prevent HF (stage B), and reduce symptoms, morbidity, and mortality (stages C and D).
Given this patient’s family and social histories, along with the clinical finding of elevated blood pressure, he is best classified as having Stage A, or at risk for HF.
253. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Perspectives from Writing Committee Chair Dr. Paul Heidenreich
Jan 08, 2023
Join CardioNerds (Dr. Mark Belkin and Dr. Natalie Tapaskar) as they discuss the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure with Writing Committee Chair Dr. Paul Heidenreich. They discuss how one gets involved with a guideline writing committee, the nuts and bolts of the guideline writing process, pitfalls and utility of the term “GDMT,” background behind inclusion of “Value Statements,” potential omissions from the document, clinical uptake of recommendations, and anticipated changes for the next iteration. Audio editing by CardioNerds academy intern, Pace Wetstein.
This discussion is a prelude to the CardioNerds Decipher The Guidelines Series designed to enhance understanding and uptake of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. We will be using high-impact, board-style, clinical vignette-based questions to highlight core concepts relevant to your practice. We will do so by releasing several short bite-sized Pods with one question per episode. Note that the cases used are hypothetical and created solely to illustrate core concepts.
This series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.
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252. Cardio-Oncology: Cardiac Amyloidosis with Dr. Omar Siddiqi
Jan 06, 2023
The importance of recognition and diagnosis of cardiac amyloidosis is at an all-time high due to its high prevalence and improved therapeutic strategies. Here we discuss what CardioNerds need to know about the manifestations, diagnosis, and management of transthyretin (ATTR) and light chain (AL) cardiac amyloidosis. Join Dr. Dan Ambinder (CardioNerds Cofounder), Dr. Dinu-Valentin Balanescu (Series Cochair, Chief Resident at Beaumont Health, and soon FIT at Mayo Clinic), and Dr. Dan Davies (Episode FIT Lead and FIT at Mayo Clinic) as they discuss cardiac amyloidosis with Dr. Omar Siddiqi, cardiologist at the Boston University Amyloidosis Center and program director for the general cardiovascular fellowship program at Boston University, a CardioNerds Healy Honor Roll Program. Episode notes were drafted by Dr. Dan Davies. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
Access the CardioNerds Cardiac Amyloidosis Series for a deep dive into this important topic.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes
Cardiac amyloidosis is no longer considered a rare disease, especially transthyretin amyloidosis in older male patients with HFpEF and aortic stenosis.
Echocardiogram is the “gate keeper” of cardiac imaging and provides initial evidence of amyloid infiltration, while cardiac MRI can help refine the presence of an infiltrative cardiomyopathy versus other causes of increased wall thickness.
The most clinically important types of amyloid heart disease are transthyretin (ATTR) and light chain (AL) amyloidosis. The workup to differentiate these disorders includes a gammopathy panel to screen for the presence of potentially amyloidogenic light chains (serum and urine electrophoresis WITH immunofixation and serum free light chains), and cardiac scintigraphy with Technetium-99m-labeled bone-seeking tracers (PYP, DPD, etc.) to identify cardiac aTTR infiltration if the gammopathy panel is unrevealing.
There is still a role for endomyocardial biopsy in the diagnosis of cardiac amyloidosis! All patients in whom there is concern for cardiac amyloidosis and gammopathy panel indicates the presence of monoclonal light chains should have a biopsy to obtain a tissue diagnosis of likely AL amyloidosis. Alternatively, an endocardial biopsy may prove valuable in patients who have confusing phenotypic features between amyloid types, such as a patient with abnormal monoclonal protein and positive PYP imaging.
Be suspicious of heart failure patients that do not tolerate typical medications that lower heart rate. In the restrictive cardiomyopathy of cardiac amyloidosis, patients are reliant on higher heart rates to compensate for the inability to augment stroke volume.
Be suspicious of amyloidosis in patients with recurrent left atrial thrombi despite anticoagulation.
Show notes
CardioNerds Cardiac Amyloid, updated 1.20.21
1. What is cardiac amyloidosis and how common is it?
Cardiac amyloidosis is adisorder caused by misfolding of proteins into insoluble forms which are deposited into extracellular spaces of the heart, commonly causing a stiff and thick heart with progressive diastolic dysfunction with restrictive hemodynamics and ensuing heart failure.
The two most common types of amyloid protein that affect the heart are transthyretin (ATTR) and light chain (AL).
251. CCC: Palliative Care and Shared Decision-Making in the CICU with Dr. Larry Allen
Jan 01, 2023
This episode is focused on Palliative Care and Shared Decision-Making in the CICU. In this episode, we learn about how the principles of palliative care and shared decision-making apply to our patients across the spectrum of cardiovascular care, especially in the cardiac intensive care unit. We discuss pivotal trials of specialty palliative care and decision aids in cardiology and how they might inform our practice to enhance patient quality of life and improve goal-concordant care. Finally, we discuss practical tips and communication strategies for how to engage patients about end-of-life decisions and topics that can be utilized from outpatient to inpatient to critical care settings.
“We need to help patients hope for the best and plan for the worst as time goes on.”
Dr. Larry Allen
Series co-chairs Dr. Eunice Dugan and Dr. Karan Desai, along with CardioNerds Co-founder Amit Goyal are joined by FIT lead, Dr. Sarah Chuzi. Dr. Chuzi is a Chicagoan and completed her internal medicine residency, cardiology fellowship, AHFTC fellowship and is now Assistant Professor at Northwestern University. Our episode expert is a true national leader in shared decision-making and palliative care in heart failure – Dr. Larry Allen, Medical Director of Advanced Heart Failure and the Co-Director of the Colorado Program for Patient-Centered Decisions at the University of Colorado School of Medicine. Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Palliative Care and Shared Decision-Making in the CICU
1. “Much of what we do in cardiology is thinking about how to make people feel better (not just improving cardiac function or length of life). So, on a day-to-day basis we are really providing primary palliative care.” – Dr. Larry Allen
2. “Risk models in cardiology can only be so accurate… While risk models can give us some grounding, we also need to embrace the concept of uncertainty, and help patients understand that there are a variety of things that might happen to them, suggest some things they might plan for, and continue to iteratively come back to the patient and reevaluate what their options are.” – Dr. Larry Allen
3. “Our goal is to help people live happy, healthy, full lives. But, everyone dies. So understanding that death is a part of life and understanding how to help them make those transitions is critical” – Dr. Larry Allen
4. “Having good deaths is a part of good healthcare. We can’t ignore that. We can’t fight against it. We should embrace it. And we have the opportunity to do that.” – Dr. Larry Allen
5. We should still keep in mind the concept of medical futility and determining what options are reasonable for patients. Part of shared decision-making includes discussing what interventions would not be feasible or helpful with patients and families
Show notes - Palliative Care and Shared Decision-Making in the CICU
Notes drafted by Dr. Sarah Chuzi.
1. How are the basic principles of palliative care relevant to cardiology, and can you define the key concepts of shared decision-making, primary palliative care, specialty (or secondary) palliative care, and hospice care?
Throughout medicine, we confront the concepts of symptom control, difficult medical decision-making, and end-of-life. These are the principles of palliative care and they apply very easily across the spec...
250. ACHD: Partial Anomalous Pulmonary Venous Return (PAPVR) with Dr. Ian Harris
Dec 26, 2022
Partial anomalous pulmonary venous return refers to anomalies in which one or more (but not all) of the pulmonary veins connects to a location other than the left atrium. This causes left to right shunting which may have hemodynamic and therefore clinical significance, warranting repair in some patients.
Join CardioNerds to learn about partial anomalous pulmonary venous return! Dr. Dan Ambinder (CardioNerds co-founder), Dr. Josh Saef (ACHD FIT at the University of Pennsylvania and ACHD Series co-chair), and Dr. Tripti Gupta (ACHD FIT at Vanderbilt University and episode lead) learn from Dr. Ian Harris (Director of the Adult Congenital Heart Disease program at University of California, San Francisco). Audio editing by CardioNerds Academy Intern, student doctor Shivani Reddy.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Partial Anomalous Pulmonary Venous Return (PAPVR)
What is partial anomalous pulmonary venous return (PAPVR)?
PAPVR refers to anomalies in which one or more (but not all) of the pulmonary veins connects to a location other than the left atrium. Often, this means one or more pulmonary veins empty into the right atrium or a systemic vein such as the superior vena cava or inferior vena cava. Physiologically, this produces a left-to-right shunt, allowing for already-oxygenated blood to recirculate into the lungs and result in excessive pulmonary blood flow.
What are the clinical features of PAPVR?Diagnosis is usually incidental on a cross sectional imaging such as CTA or CMR.The most common associated lesion is an atrial-level defect.It is unusual for a single anomalous pulmonary venous connection of only 1 pulmonary lobe to result in significant shunting.
Patients with a significant degree of left to right shunting may have right heart dilatation or symptoms of dyspnea on exertion.
When are some strategies for managing patients with PAPVR?A surgical correction is recommended for patients with PAPVR when functional capacity is impaired and RV enlargement is present, there is a net left-to-right shunt sufficiently large to cause physiological sequelae (aka: ratio of pulmonary flow (Qp) to systemic flow (Qs) is > 1.5:1), PA systolic pressure is less than 50% systemic pressure and pulmonary venous resistance is less than one third of systemic venous resistance.Surgical repair involves intracaval baffling of the left atrium (Warden procedure) or direct reimplantation of the anomalous pulmonary vein into the left atrium.Pregnancy is well tolerated in patients with repaired PAPVR. In patients with unrepaired lesion who may have right sided heart dilatation and/or pulmonary hypertension, preconception evaluation and counseling should address how pregnancy may affect mother’s and fetus’s health.
Antibiotic prophylaxis for infective endocarditis is typically not needed unless patients are less than 6 months from recent surgery, have residual defect at the patch margin or prior history of infective endocarditi...
249. CardioNerds Rounds: Challenging Cases – HFpEF Diagnosis and Management with Dr. Jane Wilcox
Dec 18, 2022
It’s another session of CardioNerds Rounds! In these rounds, Dr. Loie Farina (Advanced Heart Failure and Transplant Fellow at Northwestern University) joins Dr. Jane Wilcox (Chief of the Section of Heart Failure Treatment and Recovery at Northwestern University) to discuss the nuances of HFpEF diagnosis and management. Dr. Wilcox is also the Associate Director of the T1 Center for Cardiovascular Therapeutics in the Bluhm Cardiovascular Institute and Director of the Myocardial Recovery Clinic at Northwestern University. Dr. Wilcox is a prolific researcher, clinician, and thought leader in Heart Failure and we are honored to have her on CardioNerds Rounds! Notes were drafted by Dr. Karan Desai. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
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Show notes - HFpEF Diagnosis and Management
Case #1 Synopsis:
A woman in her 80s with a history of HFpEF presented with worsening dyspnea on exertion over the course of a year but significantly worsening over the past two months. Her other history includes prior breast cancer with chemotherapy and radiation therapy, permanent atrial fibrillation with AV node ablation and CRT-P, and CKD Stage III. She presented for an outpatient RHC with exercise to further characterize her HFpEF. Her echo showed normal LV size, no LVH, LVEF of 50%, decreased RV systolic function, severe left atrial enlargement, significantly elevated E/e’ and mild MR. Right heart catheterization showed moderately elevated bi-ventricular filling pressures at rest but with passive leg raise and Stage 1 exercise the wedge pressure rose significantly. We were asked to comment on management.
Case #1 Takeaways
Amongst the things that were discussed were the role of specific therapies in symptomatic patients with HFpEF. In patients with HFpEF and documented congestion, they will require diuretic therapy for symptomatic relief. But in addition to diuretic therapy, we discussed starting HFpEF-specific therapies. Amongst, those specific therapies mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 (SGLT2) inhibitor.
In multiple trials that have included patients with HFPEF, SGLT2i have reduced the risk of hospitalization. This includes the EMPEROR-PRESERVED Trial (see the CardioNerds Journal Club discussion on the trial) in which nearly 6000 patients with NYHA Class II-IV symptoms, EF > 40% and elevated NT-proBNP with a prior HF hospitalization within the past 12 months were randomized to Empagliflozin or placebo. The primary outcome – death from CV causes or hospitalization for Heart Failure – was significantly lower in the SGLT2i arm (13.8% vs 17.1%, 95% CI 0.69-0.90, P <0.001).
In regards to MRA, an important trial was the TOPCAT trial which randomized patients with symptomatic HF and LVEF > 45% to receive either spironolactone or placebo. The primary endpoint (death from CV cause, aborted cardiac arrest, or hospitalization for HF) was not statistically different between treatment arms. Of note, however, there were concerns for regional differences which is outlined well in this NEJM Evidence piece.
Case #2 Synopsis:
A woman in her 70s with history of hypertension, obesity,
248. Cardiovascular Genomics: Frontiers in Clinical Genetics in Cardiovascular Prevention with Dr. Pradeep Natarajan
Dec 08, 2022
As the burden of cardiovascular disease increases in the United States, the importance of enhanced screening tools, early risk prediction, and prevention strategies grows. Novel risk scoring methods, including polygenic risk scores (PRS), may help identify patients that benefit from early intervention and risk modification. In this episode, we discuss how a PRS is calculated, how to incorporate a PRS into clinical practice, and current barriers to the equitable implementation of risk scores. In terms of frontiers in clinical genetics we also discuss the burgeoning field of pharmacogenetics and how pharmacogenetics may be used to identify responders and non-responders to certain therapies.
Join CardioNerds Dr. Jessie Holtzman (CardioNerds Academy Chief and Chief Resident and soon FIT at UCSF), Dr. Alaa Diab (CardioNerds Academy Fellow and Medicine Resident at GBMC), and student doctor Hirsh Elhence (CardioNerds Academy Intern and medical student at USC Keck School of Medicine) as they discuss frontiers in clinical genetics with Dr. Pradeep Natarajan (Director of Preventive Cardiology, Massachusetts General Hospital). Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
This episode was developed in collaboration with the American Society of Preventive Cardiology and is supported with unrestricted educational funds from Illumina, Inc. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
This CardioNerds Cardiovascular Genomics series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs.
Pearls • Notes • References
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Pearls - Frontiers in Clinical Genetics in Cardiovascular Prevention
For common diseases like coronary artery disease, rare mutations may confer a several-fold increased risk of disease – for instance, in familial hypercholesterolemia, a single rare mutation may confer as much as a three-fold increase in risk of coronary artery disease. However, for most common diseases, the overall cumulative impact of several common genetic variants may be greater than that of a monogenetic trait.
Family history is a particularly coarse predictor of CV risk, highlighting the need for polygenic risk scores. In particular, younger patients with borderline cardiovascular risk may benefit from the use of a polygenic risk score in the determination of their overall cardiovascular risk profile.
A polygenic risk score (PRS) is a weighted sum of several risk-conferring alleles. The weight assigned to an allele is determined by the strength of the association between the allele and CV disease, as determined by genome-wide association studies (GWAS).
The data used for genome-wide associated studies in cardiovascular disease have historically included populations primarily of European ancestry. However, more data is being collected from diverse patient cohorts to increase the external validity and broader applicability of such studies.
Pharmacogenetic polygenic risk scores may be used to predict drug efficacy and toxicity, as well as to identify biologically plausible drug targets for clinical trial design.
Show notes - Frontiers in Clinical Genetics in Cardiovascular Prevention
What is a polygenic risk score (PRS)?
Monogenic conditions are those in which a variant in a single gene causes a pathological phenotype. For example, familial hypercholesterolemia is often the result of a mutated allele in the LDL receptor gene.
In contrast, polygenic risk suggests that there are variants in multiple genes that all confer risk independently, each with a small individual effect size. By aggregating many variants,
247. CCC: Biventricular Failure and the Use of VA-ECMO with Dr. Ann Gage
Dec 05, 2022
In this episode, we discuss the utility of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) for the temporary management of biventricular failure and cardiogenic shock requiring full cardiopulmonary support. Here, we define the types of ECMO and describe the unique physiology of this mechanical circulatory support platform, as well as review the potential complications and management strategies. Most notably, we highlight indications for and contraindications to the use of VA-ECMO and review the importance of patient selection. Lastly, we discuss de-escalation and de-cannulation strategies for patients on VA-ECMO as a bridge to recovery.
Join Dr. Amit Goyal (CardioNerds Cofounder and FIT at Cleveland Clinic), Dr. Yoav Karpenshif (Series Co-chair and FIT at University of Pennsylvania), and Dr. Megan Burke (Episode FIT Lead and FIT at University of Pennsylvania) as they learn about how to care for some of our sickest patients from Dr. Ann Gage, interventional and critical care cardiologist at Centennial Heart. At the beginning of the episode, enjoy a message from the very first CardioNerds Scholar, Dr. Katie Vaughan (Chief Resident and soon Cardiology Fellow at BIDMC). Episode notes were developed by Dr. Megan Burke. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Biventricular Failure and the Use of VA-ECMO
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support that can do the work of both the heart and lungs.
The ECMO circuit is a narcissist, i.e. cannulas are named in reference to the circuit and not the patient (“inflow” vs “outflow”).
The decision to utilize ECMO should be made by a multidisciplinary shock team and patient selection is KEY!
ECMO physiology rule #1: VA-ECMO increases LV afterload
Patients on VA-ECMO should be monitored with a PA catheter and an arterial line in the right arm
Show notes - Biventricular Failure and the Use of VA-ECMO
Notes drafted by Dr. Megan Burke.
1. What is ECMO and what are the different types?
Extracorporeal membrane oxygenation (ECMO) is a temporary form of mechanical life support that comes in two flavors: veno-arterial, or “VA” and veno-venous, or “VV.”
VV-ECMO supports extracorporeal gas exchange in the setting of acute respiratory failure
VA-ECMO provides full circulatory support in addition to gas exchange, doing the work of both the heart and lungs.
2. What are the components and “anatomy” of the VA-ECMO circuit?
The circuit is made up of the following major components:
Venous (inflow) cannula
Centrifugal Pump
Oxygenator (also responsible for CO2 removal)
Arterial (outflow) cannula
The cannulas are named in reference to the ECMO circuit, not the patient. Dr. Gage suggests that we think of the ECMO circuit (and mechanical circulatory support in general) as narcissistic, i.e. flow is always in reference to the device.
Gas exchange happens in the oxygenator. In the oxygenator blood flows through thin filaments that allow for diffusion of oxygen and carbon dioxide. Gas flows in the opposite direction of blood flow to maximize diffusion through the countercurrent effect. Oxygenation is determined by rate of blood flow through the oxygenator and FiO2 delivered. Carbon dioxide removal is determined by rate of countercurrent gas flow,
246. Cardiovascular Genomics: Genetic Counseling & Family Screening in Arrhythmogenic Cardiomyopathies with Dr. Allison Hays and Dr. Cindy James
Nov 30, 2022
The CardioNerds Cardiovascular Genomics Series continues! In this episode Dr. Dan Ambinder (CardioNerds Cofounder and Interventional Cardiologist), Dr. Anjali Wagle (FIT Ambassador at Johns Hopkins) and Dr. James Sampognaro (medicine resident at Johns Hopkins Osler Medicine Residency) learn from Dr. Allison Hays (Associate Professor of Medicine, Division of Cardiology, Johns Hopkins CMR researcher and Medical Director of Echocardiography) and Dr. Cindy James (Associate Professor of Medicine and certified genetic counselor at Johns Hopkins with research focusing on cardiovascular genetic counseling and arrhythmogenic cardiomyopathies). They discuss arrhythmogenic RV cardiomyopathy as the context to learn about genetic counseling and family screening. Episode script and notes were developed by Dr. Anjali Wagle. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This episode was developed in collaboration with the American Society of Preventive Cardiology and is supported with unrestricted educational funds from Illumina, Inc. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
This CardioNerds Cardiovascular Genomics series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs.
Check out this REVIEW describing the “Multimodality Imaging in Arrhythmogenic Right Ventricular Cardiomyopathy” by Nitin Malik, Allison Hays, and colleagues.
For related episodes, please enjoy these case-based discussions:
Ep 56. Case Report: Arrhythmogenic Desmoplakin Cardiomyopathy – Northwestern University
Ep 74. Case Report: Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) – Summa Health
Pearls • Notes • References
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Show notes - Genetic Counseling & Family Screening in Arrhythmogenic Cardiomyopathies
Notes (developed by Dr. Anjali Wagle)
What is the underlying pathophysiology of arrhythmogenic RV cardiomyopathy (ARVC)?
Fibrofatty replacement cardiac myocytes
Associated with genetically mediated disruption of desmosomal proteins
This leads to thinning and weakness of the heart that can lead to aneurysms and progressive dilatation and failure of the right ventricle (RV)
How is ARVC diagnosed?
2010 taskforce criteria (Marcus et al, 2010):
RV structural abnormalities including findings seen on echocardiogram, MRI, and RV angiography
Pathological criteria
Repolarization abnormalities
Depolarization/conduction abnormalities
Ventricular arrhythmias
Genetics and/or family history
How does ARVC present?
Young, healthy individual will have symptoms of arrhythmias (syncope, pre-syncope, SCD) or heart failure
Family screening
What are the inheritance and genetic factors of ARVC?
Autosomal dominant pattern
Low penetrance and variable expressivity
Half of patients who are index cases will be found to have a mutation in the desmosomal gene.
What are the most common mutations associated with ARVC?
Most commonly the genes involved are plakophilin-2 (PKP-2) and desmoplakin.
For PKP-2 the most common mutations are truncating mutations.
In patients who have inherited two truncating mutations, this will result in neonatal lethality.
Is there a difference in the genetic factors of left and right arrhythmogenic cardiomyopathy?
ACM is disproportionally a right dominated cardiomyopathy. Left dominated cardiomyopathy has a different genetic profile.
Pathogenic variants in desmoplakin disproportionally cause biventricular forms of ACM or left dominated forms.
245. ACHD: Ventricular Septal Defects with Dr. Keri Shafer
Nov 28, 2022
Congenital heart disease is the most common birth defect, affecting 1 in 100 babies. Amongst these ventricular septal defects are very common with the majority of patients living into adulthood. In this episode we will be reviewing key features of VSDs including embryologic origin, anatomy, physiology, hemodynamic consequences, clinical presentation and management of VSDs. Dr. Tommy Das (CardioNerds Academy Program Director and FIT at Cleveland Clinic), Dr. Agnes Koczo (CardioNerds ACHD Series Co-Chair and FIT at UPMC), and Dr. Anu Dodeja (Associate Director for ACHD at Connecticut Children’s) discuss VSDs with expert faculty Dr. Keri Shafer. Dr. Shafer is an adult congenital heart disease specialist at Boston Children’s Hospital, and an assistant professor of pediatrics within Harvard Medical School. She is a medical educator and was an invited speaker for the inaugural CardioNerds Sanjay V Desai Lecture, on the topic of growth mindset. Script and notes were developed by Dr. Anu Dodeja. Audio editing by CardioNerds Academy Intern, Shivani Reddy.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Ventricular Septal Defects
Most common VSDs: Perimembranous VSD
The shunt volume in a VSD is determined largely by the size of the defect and the pulmonary vascular resistance. VSDs cause left to right shunt. The long-term effects are left sided chamber dilation, as is the case with PDAs (post-tricuspid shunts)
VSDs can be associated with acquired RVOTO, double chamber right ventricle, LVOTO/sub aortic membrane formation, and aortic regurgitation from aortic valve prolapse.
Eisenmenger syndrome results from long-term left-to-right shunt, usually at higher shunt volumes. The resulting elevated pulmonary artery pressure is irreversible and leads to a reversal in the ventricular level shunt, desaturation, cyanosis, and secondary erythrocytosis.
Endocarditis prophylaxis is not indicated for simple VSD. It is required for 6 months post VSD closure, in patients post VSD closure with a residual shunt and in Eisenmenger patients with R—>L shunt and cyanosis.
Show notes - Ventricular Septal Defects
Notes (developed by Dr. Anu Dodeja):
What are types OF VSD? (Please note that there are several nomenclatures)
Perimembranous VSDMost common type of VSD - 80% of VSDsOccurs in the membranous septum and can be associated with inlet or outlet extensionLocated near the tricuspid and aortic valves, often time can be closed off by tissue from the septal leaflet of the tricuspid valve and associated with abnormalities in the septal leaflet of the tricuspid valve secondary to damage from the left to right shuntCan be associated with acquired RVOTO, double chamber right ventricle, LVOTO/sub aortic membrane formation
On TTE, the parasternal short axis view at the base demonstrates this type of VSD at the 10-12 o’clock position.
Muscular VSDSecond most common VSD - 15-20% of VSDsCompletely surrounded by muscle,
244. Cardiovascular Genomics: Intro to Cardiovascular Genetics in Electrophysiology with Dr. James Daubert
Nov 24, 2022
The field of Cardiovascular Genomics has advanced tremendously over the past two decades, having a significant clinical impact and changing the perception of the role and scope of genetic testing in several cardiovascular domains. To kickstart the Cardiovascular Genomics series, CardioNerds Dr. Sara Coles (FIT at Duke University), Dr. Colin Blumenthal (CardioNerds Academy faculty and FIT at UPenn), and Dr. Karla Asturias (CardioNerds Academy fellow and medicine resident at Pennsylvania Hospital) have a great discussion with Dr. James Daubert, a clinical electrophysiologist at Duke University, with a particular interest in inherited arrhythmia syndromes and sports cardiology. In this episode, we review basic concepts of cardiovascular genomics and genetics in electrophysiology while discussing when to (and when not to!) test our patients and their families and how to approach those results. Audio editing by CardioNerds academy intern, Pace Wetstein.
This episode was developed in collaboration with the American Society of Preventive Cardiology and is supported with unrestricted educational funds from Illumina, Inc. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
This CardioNerds Cardiovascular Genomics series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs.
Pearls • Notes • References
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Pearls and Quotes - Genetics in Electrophysiology
The first step is identifying the right phenotype! Getting the right phenotype is crucial, as genetic testing done in a patient without a clear phenotype (or an incorrect one) would lead to significant anxiety, unnecessary tests and interventions, and potentially misleading and dangerous conclusions for patients and their families. Genetic testing typically should be reserved for patients with a confirmed or suspected diagnosis of an inherited disease or for individuals with a previously diagnosed pathogenic variant in a first-degree relative.1
Discuss with your patient! Genetic counseling is essential and recommended for all patients before and after genetic testing. It should include a thorough discussion of risks, benefits, and possible outcomes, including variants of uncertain significance.2
Cardiovascular genetics is a dynamic and rapidly evolving field. New information can cause a variant of uncertain significance to be reclassified as a pathogenic or likely pathogenic variant or to be downgraded to benign or likely benign as variant databases expand. Another possibility is that new research might identify novel genes for a particular disease, which could warrant retesting, particularly for phenotype-positive and genotype-negative patients.1
Brugada syndrome is an inherited arrhythmogenic disorder characterized by ST-segment elevation in the right precordial leads and malignant ventricular arrhythmias, with occasional conduction disease and atrial arrhythmias. It is diagnosed in patients with ST-segment elevation ≥ 2 mm in ≥ 1 lead among the right precordial leads, with a type I morphology (J-point elevation with slowly descending or concave ST segment elevation merging into a negative T wave), shown in the image below. This pattern can be observed spontaneously or after provocative drug testing (e.g., procainamide). Pathogenic genetic variants in SCN5A that result in loss of function of the cardiac sodium channel are identified in approximately 20% of cases.3,4
Image adapted from Batchvarov VN. The Brugada Syndrome – Diagnosis, Clinical Implications and Risk Stratification. Eur Cardiol Rev. 2014;9(2):82. doi:10.15420/ECR.2014.9.2.82
Measure the QT interval yourself!
243. Case Report: A Rare Case of Isolated Non-Compaction Cardiomyopathy – Mount Sinai Medical Center in Miami
Nov 20, 2022
CardioNerds Cofounder Dr. Amit Goyal is joined by Dr. Douglas Salguero (Internal medicine resident), Dr. Francisco Ujueta (Cardiology fellow), and Dr. Priscilla Wessly (Chief cardiology fellow) from the Columbia University Division of Cardiology at Mount Sinai Medical Center in Miami to discuss a rare case of isolated non-compaction cardiomyopathy. Expert commentary is provided by Dr. Christos Mihos (Director, Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Medical Center). Audio editing by CardioNerds Academy Intern, Shivani Reddy.
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Case Media - Non-Compaction Cardiomyopathy
Episode Schematics & Teaching
The etiology has been a constant debate since 1980. It has been debated among researchers and clinicians whether LVNC is a physiologic or a pathologic manifestation. Waning et al., classified 327 unrelated patients into 3 categories: 1) genetic, 2) probably genetic, or 3) sporadic, identifying the most common mutations: MYH7, MYBPC3 and TTN in the genetic LVNC patients, which mostly encode for sarcomere, Z-disc and nuclear-envelope proteins. This supports the hypothesis that the inherited phenotype can arise from a gene mutation possibly during embryogenesis, disrupting the physiologic compaction of normally developing myocardium, which progresses from the base to the apex of the cardiac tissue. It is estimated that genetic LVNC accounts approximately 18-44% of cases, with autosomal dominant transmission being the most common form of inheritance. Physiologic remodeling with prominent trabeculations may be noted in athletes and pregnant women, in comparison to pathologic remodeling which may be encountered in patients with cardiomyopathy (e.g. pressure or volume load). (1)
There is no pathognomonic signs or symptoms in LVNC. LVNC patients may encounter various potential clinical characteristics. Presentations are myriad and include heart failure symptoms (HFrEF or HFpEF), ventricular tachycardia (VT/VF), atrial fibrillation, thromboembolism including cerebrovascular accident (CVA), and syncope. In a cohort of 95 probands with LVNC investigated in Europe, as many as 32.3% had an ICD/CRT-D implantation, with 11.8% experiencing a cardiovascular death and 18.2% having an appropriate ICD shock. (2)
Imaging plays a key role in diagnosis for LVNC. The identification and diagnosis of LVNC is evaluated using 2D echocardiography. The initial proposed method by Chin et al., evaluated the size of the trabeculation in the center. (3) The most commonly used criteria, Jenni et al. (4), entail the following four finding:
Two-layer structure, with a thin compacted layer and a thick non-compacted layer measure at end-systole at the parasternal short-axis view. LVNC is defined by a ratio of N/C > 2
Absence of co-existing cardiac structural abnormalities
Prominent, excessive trabeculations and deep intra-trabecular recesses
Recesses supplied by intraventricular blood on color doppler
Cardiac MRI has increased the diagnostic accuracy in the diagnosis of LVNC. It has been suggested that a NC/C ratio of > 2.3 in diastole distinguished pathological non-compaction, with sensitivity of 86% and a specificity of 99%, respectively. Although studies have shown an increase specificity with cardiac MRI, caution is needed as it may overestimate the presence of LVNC. Late gadolinium enhancement which suggests myocardial fibrosis or scar has been shown to have some prognostic value in LVNC patients. (5)
Management for LVNC is multifaceted. As above,LVNC has a variety of presentations and prevailing manifestations will differ among patients. Therefore, the diagnostic and management approach much be personalized for a given patient...
242. ACHD: Atrial Septal Defects with Dr. Richard Krasuski
Nov 15, 2022
CardioNerds (Dan Ambinder), episode lead Dr. Sarah Fahnhorst (ACHD Cardiologist at Spectrum Health in Grand Rapids, Michigan), and series co-chair Dr. Agnes Koczo (fellow at UPMC) learn about ASD from Dr. Richard Krasuski (ACHD Cardiologist and Director of ACHD at Duke University). Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares
An atrial septal defect (ASD) is a common congenital heart disease most often diagnosed in childhood, but initial presentation can be in adulthood. ASDs are abnormal communications between the left and the right atrium. There are four types of ASDs with different embryologic origins. If the defects are large, they will require percutaneous or surgical closure. Unrepaired defects can lead to symptoms of shortness of breath, exercise intolerance, recurrent chest infections, or pulmonary hypertension. This episode of CardioNerds will review the natural history, embryologic origin, diagnostic modalities/findings, indication for closure and long term complications of repaired and unrepaired atrial septal defects.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Atrial Septal Defects
It’s a CLASSIC! – On physical exam a wide fixed split S2 along with a systolic ejection murmur due to increased blood flow across the pulmonary valve and potentially a diastolic rumble across the tricuspid valve are CLASSIC findings with atrial septal defects. Atrial septal defects are not all the same. There are four types of atrial septal defects: secundum ASD, primum ASD, sinus venosus and coronary sinus defects (NOTE – the latter are atrial level defects which actually do not involve the interatrial septum). The different types warrant a different approach to closure. Use your tools and if your suspicion is high for an atrial septal defect, keep looking. Sinus venosus defects can easily be missed since the superior vena cava is difficult to image in adults. Diagnostic tools include: history and physical exam (USE the stethoscope), ECG, echocardiogram, cardiac MRI, cardiac CT, and cardiac catheterization.Not all defects NEED to be closed immediately. Moderate-large defects with a shunt greater than 1.5:1 should be closed due to increased risk of pulmonary hypertension and arrhythmias, barring contraindications. Surgery was previously the gold standard for closure of ASDs, but many defects especially secundum atrial septal defects are closed in the cath lab.
Show notes - Atrial Septal Defects
Notes (developed by Dr. Sarah Fahnhorst
What are the four different types of atrial level defects?Secundum atrial septal defectMost common type of atrial septal defect (75%)Located in the center of the atrial septum (fossa ovalis)Hole in the primum septum due to deficiency of the septum secundumPrimum atrial septal defectAccounts for 15-20% of ASDLocated at the inferior portion of the atrial septumIn the spectrum of atrioventricular septal defects/endocardial cushion defectsDefect in the developme...
241. Case Report: A Massive Surprise – UCLA
Nov 11, 2022
CardioNerds Cofounder Dr. Amit Goyal is joined by an esteemed group of UCLA cardiology fellows – Dr. Patrick Zakka (CardioNerds Academy Chief), Dr. Negeen Shehandeh (Chief Fellow), and Dr. Adrian Castillo – to discuss a case of primary cardiac angiosarcoma. An expert commentary is provided by Dr. Eric Yang, beloved educator, associate clinical professor of medicine, assistant fellowship program director, and founder of the Cardio-Oncology program at UCLA.
Case synopsis: A female in her 40s presents to the ED for fatigue that had been ongoing for approximately 1 month. She also developed night sweats and diffuse joint pains, for which she has been taking NSAIDs. She was seen by her PCP and after bloodwork was done, was told she had iron deficiency so was on iron replacement therapy. Vital signs were within normal limits. She was in no acute distress. Her pulmonary and cardiac exams were unremarkable. Her lab studies showed a Hb of 6.6 (MCV 59) and platelet count of 686k. CXR was without significant abnormality, and EKG showed normal sinus rhythm. She was admitted to medicine and received IV iron (had not consented to receiving RBC transfusion). GI was consulted for anemia work-up. Meanwhile, she developed a new-onset atrial fibrillation with rapid ventricular response seen on telemetry, for which Cardiology was consulted. A TTE was ordered in part of her evaluation, and surprisingly noted a moderate pericardial effusion circumferential to the heart. Within the pericardial space, posterior to the heart and abutting the RA/RV was a large mass measuring approximately 5.5x5.9 cm. After further imaging work-up with CMR and PET-CT, the mass was surgically resected, and patient established care with outpatient oncology for chemotherapy.
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Case Media - primary cardiac angiosarcoma
Episode Schematics & Teaching
Pearls – primary cardiac angiosarcoma
The pericardium is composed of an outer fibrous sac, and an inner serous sac with visceral and parietal layers.
Pericardial masses can be primary (benign or malignant) or metastatic. There are other miscellaneous pericardial masses.
Imaging modalities for the pericardium include echocardiography, cardiac CT and cardiac MRI. There is also role for PET-CT in pericardial imaging for further characterization of pericardial masses.
Cardiac angiosarcomas are extremely rare but are the most common cardiac primary malignant tumors.
Evidence-based management if lacking because of paucity of clinical data given the rarity of cardiac angiosarcomas. Surgery is the mainstay of therapy. Radiotherapy and chemotherapy are often used as well.
Notes – primary cardiac angiosarcoma
Pericardial Anatomy
The pericardium is a fibroelastic sac composed of two layers.
Outer layer: fibrous pericardium (<2 mm thick)
Inner layer: serous pericardium, two-layered sac.
Visceral pericardium: adherent to underlying myocardium Parietal pericardium: lines fibrous sac.
Between the serous layers, there is the pericardial cavity which normally contains up to 50 cc pericardial fluid.
Pericardial Masses
Benign
Lipoma: slow-growing, collection of adipose cells, thought to arise in AV groove Teratoma: benign germ cell tumors, often right sided. Can cause compressive symptoms of RA, SVC, PA, aortic root. Fibroma: solid mass of connective tissue Hemangioma: vascular mass, often arising from visceral pericardium
Malignant
Sarcoma: various types including angiosarcoma and liposarcoma. Lymphoma: usually non-Hodgkin B-cell lymphoma, often in immunocompromised patients Mesothelioma: no apparent association with asbestos. Pericardial effusions with nodules/plaques are seen.
240. CardioNerds Rounds: Challenging Cases – Antithrombotic Management with Dr. Deepak Bhatt
Nov 03, 2022
It’s another session of CardioNerds Rounds! In these rounds, Dr. Priya Kothapalli (Interventional FIT at University of Texas at Auston, Dell Medical School) joins Dr. Deepak Bhatt (Dr. Valentin Fuster Professor of Medicine and Director of Mount Sinai Heart) to discuss the nuances of antithrombotic therapy. As one of the most prolific cardiovascular researchers, clinicians, and educators, CardioNerds is honored to have Dr. Bhatt on Rounds, especially given that Dr. Bhatt has led numerous breakthroughs in antithrombotic therapy. Come round with us today by listening to the episodes of #CardsRounds! Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
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Show notes - Antithrombotic Management with Dr. Deepak Bhatt
Case #1 Synopsis:
A woman in her early 70s with a history of hypertension, hyperlipidemia, and paroxysmal atrial fibrillation presented with sudden-onset chest pressure and diaphoresis while at rest and was found to have an acute thrombotic 99% mid-LAD occlusion. The patient received OCT-guided PCI with a single drug-eluting stent. We discussed what the appropriate antithrombotic strategy would be for a patient with recent acute coronary syndrome and atrial fibrillation.
Case #1Takeaways
According to the recent 2021 revascularization guidelines, in patients with atrial fibrillation undergoing PCI and taking oral anticoagulant therapy, it is recommended to discontinue aspirin after 1 to 4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K oral anticoagulant or warfarin.There are two recent trials – AUGUSTUS and the ENTRUST-AF PCI trial – that evaluated regimens of apixaban and edoxaban, respectively, that support earlier findings reporting lower bleeding rates in patients maintained on oral anticoagulant plus a P2Y12 inhibitor compared to triple therapy.Of note, none of these trials were specifically powered for ischemic endpoints, but when pooling data from these trials, rates of death, MI and stent thrombosis with dual therapy were similar to those seen in patients on triple therapy.Additionally, all of these patients enrolled in these trials were briefly treated with triple therapy after PCI before the aspirin was discontinued. In the 2021 guidelines, it is noted that analyses of stent thrombosis suggest that 80% of events occur within 30 days of PCI. Thus, it is reasonable to consider extending triply therapy to 1 month after PCI in high risk patients to reduce risk of stent thromboses.In AUGUSTUS, 90% of patients received clopidogrel as their P2Y12 inhibitor
Case #2 Synopsis:
A man in his mid-50s with a history of peripheral vascular disease with prior SFA stent for chronic limb ischemia, hyperlipidemia, tobacco use, diabetes, and chronic kidney disease presented with a two day history of “reflux” that was worse with exertion and that improved with rest and associated with diaphoresis. He was diagnosed with an NSTEMI. His LHC revealed 99% mid-RCA thrombotic occlusion with moderate disease in the LAD. He underwent thrombectomy and PCI with a single drug-eluting stent to the RCA. We discussed his short-term and long-term antithrombotic therapy
Case #2 Takeaways
239. CCC: Approach to RV Predominant Cardiogenic Shock with Dr. Ryan Tedford
Oct 23, 2022
CardioNerd (Daniel Ambinder) and series co-chairs Mark Belkin (AHFT Fellow, University of Chicago) and Karan Desai (Cardiologist, Johns Hopkins), join fellow lead, Dr. Pablo Sanchez (FIT, Stanford) for a discussion with Dr. Ryan Tedford (Professor of Medicine at the Medical University of South Carolina) about Right Ventricular (RV) predominant cardiogenic shock. In this episode we explore risk factors, pathophysiology, hemodynamics, and treatment strategies in this common and complex problem. We dissect three cases that epitomize the range of diagnostic dilemmas and management decisions in RV predominant shock, as Dr. Tedford expertly weaves us through the pathophysiology and decision-making involved in managing the “people’s ventricle.” Audio editing by Dr. Gurleen Kaur (Director of the CardioNerds internship program, CardioNerds academy fellow, and IM resident at Brigham and Women’s Hospital).
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - RV Predominant Cardiogenic Shock
The degree of RV dysfunction and failure are modulated by stretching its capacity to tolerate insults from deranged afterload, preload, and contractility.Afterload insults are MUCH LESS tolerated than other insults and broadly comprise the most common pathophysiologic cause of both acute and chronic RV failure.RV and left ventricular (LV) function are anatomically and physiologically connected. Progressive derangements in RV function can lead to the deadly “RV spiral,” in which poor RV function causes lower LV preload, leading to hypotension, and thus worsening RV perfusion and function.In RV failure/shock, some basic tenets including treating reversible causes, optimizing preload and afterload, and using inotropes and/or temporary MCS for as limited time as possible.Many acute RV failure patients can recover, but multiorgan injury plays an important role. Therefore, thoughtful and expeditious use of mechanical circulatory support is important.
Show notes - RV Predominant Cardiogenic Shock
Notes drafted by Dr. Pablo Sanchez.
What is the basic difference between RV dysfunction and failure?Dysfunction: Abnormalities in systolic/diastolic function of the RV, but not necessarily to the point of leading to end-organ perfusion defects. RV dysfunction leads to poor outcomes regardless of mechanism.1Failure: Clinical syndrome of inability of RV to maintain adequate output despite adequate preload. 1
How is the RV different from the LV and what impact does it have on pathophysiology and hemodynamics?The LV and RV originate from different embryologic “heart fields.”1,2The RV wall is thinner and more compliant and has only two layers (instead of 3 like the LV).3 Furthermore, unlike the LV which has a significant proportion of endocardial and epicardial transverse myocardial fibers, the RV myocardial fibers are aligned in a longitudinal plane for the most part. Thus, a more significant proportion of RV systolic contraction is longitudinal – base of the ventricle moving towards the apex.The RV is crescent-shaped and has a large surface-to-volume ratio meaning smaller inward motion ejects the same stroke volume. 1Hemodynamically, the RV takes blood from a low-pressure venous system and gives it to a distensible system with low impedance (the normal pulmonary circuit at baseline typically has a resistance one-tenth of the systemic resistance). Therefore, volume loads (preload) are much better handled...
238. Cardio-Oncology: Radiation-Associated Cardiovascular Disease with Dr. Eric Yang
Oct 13, 2022
CardioNerds (Dr. Patrick Azcarate, Dr. Teodora Donisan, and Amit Goyal) discuss Radiation-Associated Cardiovascular Disease (RACD) with Dr. Eric Yang, cardio-oncologist, assistant professor of medicine, and associate fellowship program director at UCLA.
RACD is a consequence of radiation treatment for various mediastinal tumors (breast, lung, lymphoma). It is the second most common cause of morbidity and mortality in patients treated with mediastinal radiation for cancer. While novel techniques decrease radiation exposure during cancer treatment, the incidence is expected to increase because of historical practices and delayed onset of symptoms. The prevalence of RACD is difficult to estimate given under-recognition. Additionally, most of the data comes from patients treated with radiation techniques from decades ago. In this discussion we review every nook and cranny of RACD to help guide you the next time you see a patient with a history of chest radiation.
Review this CardioNerds Case Report of radiation associated cardiovascular disease for more: Episode #169. Chest pain in a Young Man – “A Gray (Gy) Area” – UC San Diego.
Audio editing by CardioNerds Academy Intern, student doctor Yousif Arif. This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Radiation-Associated cardiovascular disease
Due to the legacy effect, the incidence of RACD will continue to increase in the next few years.
When treating patients with a history of mediastinal radiation, we should remember to ask:
How much radiation was given?
Could the heart have been exposed?
Radiation can affect every part of the heart by causing coronary artery disease (CAD), valvulopathy, myocardial disease, conduction disease, and pericardial disease.
Exposure to ~25-30 Gy or more significantly increases the risk but RACD can occur at lower doses.
Try to delay surgery as much as possible and do all you can in one operation to avoid re-operation in the future.
For revascularization, percutaneous coronary intervention (PCI) is typically preferred over coronary artery bypass grafting (CABG) but the choice should be individualized in consultation with a multidisciplinary heart team experienced in the management of RACD.
In general, for aortic valve disease, transcatheter replacement is recommended over surgical aortic valve replacement. For mitral valve disease, surgical replacement is recommended over repair. Every decision should be made with a heart team approach and made unique to that specific patient.
Show notes - Radiation-Associated cardiovascular disease
Notes were drafted by Dr. Patrick Azkarate.
1. Understand the pathophysiology of RACD
Ionizing radiation has the potential to damage DNA. Both normal cells and cancer cells get damaged, but cancer has less effective DNA repair mechanisms and therefore malignant cells are more vulnerable to radiation therapy.
After radiation causes acute damage, this sets off an inflammatory cascade leading to myofibroblast activation, fibrosis and collagen deposition, and subsequent stiffening of the myocardium and vessels.
2. What may increase one’s risk of developing RACD?
Young age (<50 years-old) at the time of radiation
High cumulative dose (>30 Gy) or high dose of radiation fractions (>2 Gy/day)
Anterior or left chest radiation (breast cancer, lung cancer, lymphoma)
237. CCC: Approach to LV Predominant Cardiogenic Shock with Dr. Shashank Sinha
Oct 08, 2022
Cardiogenic shock (CS) remains a complex, multifactorial syndrome associated with significant morbidity and mortality. The CardioNerds Critical Care Cardiology Series tackles this important syndrome in a series of several episodes including: LV-predominant Shock, RV-predominant Shock, and Bi-ventricular Shock.
In this episode, we review the definitions, pathophysiology, evaluation, and contemporary management, including use of inotropes and mechanical circulatory support, of left ventricular (LV) predominant CS. Series co-chairs Dr. Eunice Dugan and Dr. Karan Desai along with CardioNerds Co-founders Dr. Amit Goyal and Dr. Daniel Ambinder were joined by FIT lead, Dr. Vanessa Blumer, the recipient of the AHA 2021 Laennec Fellow in Training Clinician Award and currently pursuing Advanced Heart Failure and Transplant fellowship at the Cleveland Clinic. Our episode expert is Dr. Shashank Sinha, an Advanced Heart Failure, Mechanical Circulatory Support, and Cardiac Transplant cardiologist, Medical Director of the Cardiac Intensive Care Unit, and Director of the Cardiovascular Critical Care Research Program at INOVA Fairfax Hospital. His illustrious career accomplishments include being a Steering Committee member and site Principal Investigator for the multicenter Cardiogenic Shock Working Group and Critical Care Cardiology Trials Network. Audio editing by CardioNerds academy intern, Anusha Gandhi.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - LV Predominant Cardiogenic Shock
LV-CS is complex! It is important to recognize that the pathophysiology of heart failure-related cardiogenic shock (HF-CS) is distinct from that of acute myocardial infarction (AMI-CS), and also crucial to differentiate between LV-dominant, right ventricular (RV)-dominant and biventricular (BiV)-shock.The SCAI SHOCK Stage Classification provides a unified and standardized vocabulary when assessing severity of CS, and facilitates communication about the diagnosis, presentation, and evolving nature of CS.Norepinephrine is considered the initial vasopressor of choice in most CS patients; the initial inotrope choice is a bit more nuanced!When considering mechanical circulatory support (MCS) for LV shock, high-quality data to guide therapy is lacking but one must always consider “the right patient, for the right device, at the right time” and remember that “pumps pump blood, decisions save lives”.Multidisciplinary, team-based care is paramount to improving survival of the critically ill patient with CS.
Show notes - LV Predominant Cardiogenic Shock
Notes drafted by Dr. Vanessa Blumer.
1. What tools do you use to define LV CS?
CS is a hemodynamically complex and multifactorial syndrome, one of the most common indications for admission to a cardiac intensive care unit, with short-term mortality ranging from 35-50%.It is defined by systemic hypoperfusion and tissue hypoxia due to a primary cardiac insult or dysfunction.Clinical criteria used to define CS typically include evidence of hypotension (classically defined as SBP < 90 mmHg for 30 minutes and/or use of vasopressors, inotropes, or MCS to maintain systolic blood pressure > 90 mmHg) AND evidence of end-organ hypoperfusion (for example, serum lactic acid > 2 mmol/L, acute kidney injury, acute liver injury, altered mental status) in the setting of acute coronary syndrome or acute decompensated heart failure.Laboratory markers,
236. CardioNerds Rounds: Challenging Cases – Mitral Regurgitation with Dr. Rick Nishimura
Oct 06, 2022
It’s another session of CardioNerds Rounds! In these rounds, Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) and Dr. Karan Desai (formerly FIT at University of Maryland and now General Cardiology faculty at Johns Hopkins) join Dr. Rick Nishimura (Professor of Medicine at Mayo Clinic) to discuss the nuances of managing mitral regurgitation through real cases. Dr. Nishimura has been an author or Chair of the ACC/AHA valve guidelines going back 20 years and has been recognized internationally as one of the world’s best educators, so you don’t want to miss the #NishFactor on these #CardsRounds! Audio editing by CardioNerds academy intern, Pace Wetstein.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
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Show notes - Mitral Regurgitation with Dr. Rick Nishimura
Case #1 Synopsis:
A man in his 70s with a history of non-ischemic cardiomyopathy (last known LVEF 15-20%) and atrial fibrillation, presented with decompensated heart failure in the setting of moderate to severe mitral regurgitation. He was diuresed, transitioned to GDMT, and referred to cardiac rehabilitation. Over the next 6 months, he continued to have debilitating dyspnea (NHYA Class IIIa) and his outpatient physicians were limited on titrating GDMT further due to hypotension. A TEE was done which demonstrated EF 15%, severe MR by color and quantitation (EROA of 0.5 cm2; Regurgitant Volume of 65 mL), systolic flow reversal in the pulmonary vein and severe tricuspid regurgitation. We were asked how we would approach this case
Case #1Takeaways
In attempting to keep the evaluation of chronic mitral regurgitation relatively simple, we should ask ourselves three primary questions: (1) What is causing the MR; (2) How much MR is there; and (3) What is the hemodynamic consequence of the MR.To the first question of what is the etiology of the MR – a simple framework is to think of the etiology as an issue of the valve (primary) or an issue of the ventricle/atria (secondary). There is further classification that can be made based on the Carpentier Classification which speaks to the valve leaflet movement and position (normal leaflet motion, excessive leaflet motion [e.g., prolapse], or restricted in systole and/or diastole [e.g., rheumatic heart disease]).During rounds, Dr. Nishimura provided some historical context in that the original valve guidelines had recommendations for intervention on primary mitral regurgitation and not secondary – given that it is considered a disease of the ventricle. Trials like the COAPT trial have greatly shifted our practice in treating secondary mitral regurgitation. Though, we have to be familiar with which patients with secondary MR would truly derive benefit from mitral valve interventionIn regards to the COAPT trial, patients with moderate to severe (3+) or severe (4+) mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were included. Dr. Nishimura makes the point that about one-third of patients intended to be enrolled in the trial were not included because they improved so much on GDMT. And thus, when evaluating patients for consideration of mitral valve intervention in secondary MR – a...
235. CCC: Post-cardiotomy Shock with Dr. Gavin Hickey and Dr. David Kaczorowski
Sep 30, 2022
In this episode, Dr. Carly Fabrizio (Advanced Heart Failure and Transplant Cardiology Physician at Christiana Care Hospital), CardioNerds Critical Care Series Co-Chair Dr. Mark Belkin (Advanced Heart Failure and Transplant Fellow at University of Chicago) and CardioNerds Co-Founder Dr. Amit Goyal (Cleveland Clinic) join Dr. Gavin Hickey (Director of the AHFTC Fellowship and medical director of the left ventricular assist device program at UPMC) and Dr. David Kaczorowski (Surgical Director for the Advanced Heart Failure center, Department of Cardiothoracic Surgery at UPMC) for a discussion on post-cardiotomy shock. Audio editing by CardioNerds Academy Intern, student doctor, Shivani Reddy.
Post-cardiotomy shock is characterized by heart failure that results in the inability to wean from cardiopulmonary bypass or develops post cardiac surgery. Patients who develop post-cardiotomy shock typically require inotropic support and may ultimately require temporary mechanical circulatory support. Post-cardiotomy shock carries a high mortality rate. However, early recognition and prevention strategies can help mitigate the risk for developing post-cardiotomy shock.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Post-cardiotomy Shock
Weaning from cardiopulmonary bypass is an intricate process that includes: rewarming the patient, de-airing the cardiac chambers, ensuring a perfusing heart rhythm, confirming adequate ventilation and oxygenation, removing the intracardiac catheters and cannulas and slowly reducing the blood diverted to the cardiopulmonary circuit and returning it small aliquots to the patient. Much to monitor during the process!
Assessing the risk for post-cardiotomy shock prior to going to the OR is important. Consider left ventricular, right ventricular, and valvular function, and don’t forget about the value of hemodynamic assessments (pulmonary artery catheter evaluations) to ensure patients are adequately compensated.
Close peri-operative monitoring of hemodynamics, hemo-metabolic derangements, and acid/base status can help identify patients who are failing therapy and may require upgrade to temporary MCS.
RV assessment is challenging. Utilizing both imaging and hemodynamic evaluations can help understand which RV’s will require more support.
Multi-disciplinary discussions with a heart team approach prior to cardiac surgery are valuable in identifying high risk patients for post cardiotomy shock and discussing contingency plans if issues arise.
Show notes - Post-cardiotomy Shock
(drafted by Dr. Carly Fabrizio)
How can we diagnose post cardiotomy shock?We can diagnose post cardiotomy shock as patients who are undergoing cardiac surgery that develop hypotension and or tachycardia with hypoperfusion and end organ dysfunction.
How can assess the risk of developing postcardiotomy shock prior to going to the OR?LV systolic function is not the only evaluation of cardiac functionDon’t ignore the RV!Valvular function must be evaluated in conjunction with LV/RV functionHemodynamics can be helpful prior to going to the ORFilling pressures and CO/CI evaluation --> the more normal range - the less risk of post cardiotomy shockIf going in more deranged --> more complications are likely to occurThink about what options are available post operatively if issues ariseInclude a multi-disciplinary discussions and planning prior to going to the OR
...
234. Narratives in Cardiology: Structural Heart Disease and LatinX Representation in Cardiology with Dr. Mayra Guerrero – Minnesota Chapter
Sep 23, 2022
In this episode, Daniel Ambinder and Amit Goyal (CardioNerds co-founders), Dr. Gurleen Kaur (medicine resident at Brigham and Women’s Hospital and Director of CardioNerds Internship), student doctor Adriana Mares (medical student at the University of Texas El Paso/Texas Tech University Health Sciences Center El Paso, CardioNerds Academy Intern), and Dr. Teodora Donisan (general cardiology fellow at the Mayo Clinic and CardioNerds Academy Chief) discuss with Dr. Mayra Guerrero (Interventional Cardiologist and Professor of Medicine at the Mayo Clinic) about challenges with diagnosing and treating valve disease in women, as well as ideas on how to increase recruitment for women in cardiology including interventional and structural cardiology. Dr. Guerrero shares her inspiring personal journey and advice for how to navigate becoming a structural cardiologist as an international medical graduate, woman, and mother. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • Production Team
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Video version - Structural Heart Disease and LatinX Representation in Cardiology with Dr. Mayra Guerrero
https://youtu.be/KvKADqUwUHQ
Quoatables - Structural Heart Disease and LatinX Representation in Cardiology with Dr. Mayra Guerrero
“Work hard, give it your best, and your work will speak for itself. Don’t be afraid to work hard and you’ll be able to achieve anything you want.”“I’m very fortunate to have had the opportunities that I’ve had, but now it’s my responsibility and the responsibility of many to make sure that we create those opportunities and that we provide mentorship for others who may want to follow the same steps into this field.”“I get angry, it’s normal to have emotions, but what I’ve learned is to transform my anger into something good – think of a project, find a paper, do something good for your career…channel that energy to do something good.”“It’s important that even at young ages you start thinking about how to pay it forward.”“Don’t wait too long to have kids. There’s never a perfect time to be a parent. Once you decide to have a family don’t put a pause on your personal life for your career.”
Notes - Structural Heart Disease and LatinX Representation in Cardiology with Dr. Mayra Guerrero
Notes (by Dr. Teodora Donisan)
Structural valve disease in women and valve care in the global settingHeart disease is the leading cause of death for women. However, the awareness regarding this major public health concern has been declining over the past decade. Valve disease awareness is one of the lowest, at less than 3%.Women have higher mortality than men when they undergo surgical aortic or mitral interventions, mainly because of a higher risk profile. For example, women with severe aortic stenosis usually present at older ages and have many associated comorbidities, however the outcomes are good when they are treated with transcatheter aortic valve replacement (TAVR). Despite this, women are less likely to be referred for aortic valve replacement (AVR) than men.
233. Cardio-Oncology: The Need for Cardio-Oncology with Dr. Bonnie Ky
Sep 19, 2022
CardioNerds (Amit Goyal and Dan Ambinder), Series Co-Chair Dr. Dinu Balanescu (Academy House Faculty and Chief Resident at Beaumont Hospital), and Episode Lead Dr. Manu Mysore (Former CardioNerds Ambassador and Cardiologist at the University of Maryland) discuss The Need for Cardio-Oncology with Expert Faculty Dr. Bonnie Ky, Director of Penn Cardio-Oncology Translation Center of Excellence and Editor-in-Chief of JACC CardioOncology. Audio editing by CardioNerds Academy Intern, student doctor Yousif Arif. This episode is supported by a grant from Pfizer Inc.
Cardio-Oncology is a burgeoning field. There is a need for cardiologists and oncologists to work together in a multidisciplinary fashion using multi-modality imaging and personalized medicine. Cardiologists in particular need to understand basic oncology, anti-cancer therapies, and address risk factors which play an important role in oncologic progression and/or adverse cardiovascular events. The field can only be furthered by research with a focus on specificity of endpoints and multidisciplinary collaboration. The future of the field is in the hands of investigators and clinicians alike.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Pearls • Notes • References • Production Team
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Pearls and Quotes - The Need for Cardio-Oncology with Dr. Bonnie Ky
Over 20 million new cancer cases are expected to be added annually to the global burden as novel therapies have improved cancer survivorship. These therapies may be directly associated with cardiotoxicity or may prolong life to allow time for cardiovascular disease to develop in cancer survivors.
Hypertension, hyperlipidemia, and obesity are modifiable risk factors that portend a poor prognosis from both an oncologic and cardiovascular perspective.
Multi-modality imaging is useful in risk assessment within oncology, with echocardiography (including strain imaging) having a class I indication prior to treatment with many chemotherapeutics.
Diverse trial enrollment is essential for furthering the science within Cardio-Oncology to translate clinically into personalized management.
There is a need to strengthen a pipeline of young physicians and scientists to further the field of Cardio-Oncology.
Show notes - The Need for Cardio-Oncology with Dr. Bonnie Ky
Why should cardiologists have familiarity with cancer therapies?
By 2030, 23.6 million new cancer cases are expected to be added annually to the global burden.1
Novel therapies and/or combination therapies have improved cancer survivorship but are associated with cardiovascular complications, especially in the elderly and those with pre-existing cardiovascular comorbidities.2
Cardiologists currently lack an understanding of oncologic treatments, with poor knowledge of dosing protocols and cardiotoxicities. This can lead to less aggressive protocols administered, as well as early discontinuation of important treatments for both oncologic and cardiovascular conditions.3
A multidisciplinary collaboration between pharmacists, cardiologists, oncologists, and nurse navigators is needed to improve treatment decision-making for the benefit of cancer patients.
Cardiologists should have basic knowledge and understanding of some of the commonly used chemotherapeutic drugs and any adverse events during treatment courses based on clinical trials, FDA reporting, and epidemiological data.
JACC Cardio-Oncology seeks to disseminate knowledge through live courses such as Advancin...
232. Case Report: A String of Pearls Not Worth Keeping – Emory University
Sep 16, 2022
CardioNerds (Daniel Ambinder and Amit Goyal) join Dr. Arielle Schwartz (Emory University cardiology fellow), Dr. Joshua Zuniga (former Emory vascular medicine fellow and now USC cardiology fellow), and Dr. Patrick Zakka (UCLA cardiology fellow) from the Emory University School of Medicine. They discuss a case of a young woman with new onset hypertension refractory to 3 antihypertensive agents who is ultimately diagnosed renovascular hypertension due to fibromuscular dysplasia complicated by saccular aneurysm. Dr. Bryan Wells (Director of Vascular Medicine at Emory University) provides the ECPR for this episode. Audio editing by CardioNerds Academy intern, Dr. Christian Faaborg-Andersen.
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Case Media
References
Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, Bruno RM, de Leeuw P, Fendrikova-Mahlay N, Froehlich J, Ganesh SK, Gray BH, Jamison C, Januszewicz A, Jeunemaitre X, Kadian-Dodov D, Kim ES, Kovacic JC, Mace P, Morganti A, Sharma A, Southerland AM, Touzé E, van der Niepen P, Wang J, Weinberg I, Wilson S, Olin JW, Plouin PF. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med. 2019 Apr;24(2):164-189. doi: 10.1177/1358863X18821816. Epub 2019 Jan 16. Erratum in: Vasc Med. 2019 Oct;24(5):475. Erratum in: Vasc Med. 2021 Aug;26(4):NP1. PMID: 30648921.
Olin, Circulation. 2014;129:1048-1078. Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions A Scientific Statement From the American Heart Association
S.H.KimMD, MPH†Jeffrey W.OlinDO‡James B.FroehlichMD, MPH§XiaokuiGuMA§J. MichaelBacharachMD‖Bruce H.GrayDO¶Michael R.JaffDO#Barry T.KatzenMD∗∗EvaKline-RogersMS, RN, NP§Pamela D.MaceRN††Alan H.MatsumotoMD‡‡Robert D.McBaneMD§§Christopher J.WhiteMD‖‖Heather L.GornikMD, MHS†. Clinical Manifestations of Fibromuscular Dysplasia Vary by Patient Sex: A Report of the United States Registry for Fibromuscular Dysplasia. JACC. Volume 62, Issue 21, 19–26 November 2013, Pages 2026-2028
231. ACHD: Congenital Heart Disease and Psychosocial Wellbeing with Dr. Adrienne Kovacs and Dr. Lauren Lastinger
Sep 12, 2022
CardioNerds Dr. Josh Saef, Dan Ambinder, join Dr. Jim Kimber and interview experts Dr. Adrienne Kovacs, and Dr. Lauren Lastinger and discuss behavioral health needs and psychosocial wellbeing in the congenital heart disease population. In this episode, our experts tackle issues surrounding mental and behavioral health including anxiety/depression, ADHD, neurodevelopmental disabilities, psychosocial challenges, stressors unique to patients with ACHD and their families, and how the healthcare system can better optimize mental health care for the CHD patient population. Audio editing by CardioNerds Academy Intern, Pace Wetstein.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Congenital Heart Disease and Psychosocial Wellbeing
Among patients with congenital heart disease, symptoms of anxiety are more common than symptoms of depression. “Heart-focused anxiety” relates to symptoms attributable to a heart condition including fear of appointments, surgery, or health-uncertainty. It is important to differentiate this from generalized anxiety.Predictors of depression and anxiety include patient-reported physical health status. Defect severity (mild, moderate, great complexity) and physician-diagnosed NYHA class were NOT associated with rates of depression/anxiety [2].Despite CHD, patient self-reported Quality of Life (QoL) is relatively high. Predictors of decreased QoL include older age, lack of employment, never having married, and worse self-reported NYHA functional classImportant treatment strategies include: education for patients and caregivers, early identification and referral to mental health providers, incorporation of providers into CHD teams, and encouraging physical activity and peer-interaction.
Show notes - Congenital Heart Disease and Psychosocial Wellbeing
Notes (developed by Dr. Jim Kimber)
Mental Health Terminology:
Adults with CHD face the same mental health challenges as people who don’t have a heart condition. Symptoms of depression and anxiety are the most common: Approximately 1/4 - 1/3 of CHD patients will struggle with clinically significant depression or anxiety at any one point. Up to ½ will meet lifetime diagnostic criteria for these conditions
Mood and anxiety disorders differ in that they have separate diagnostic criteria. Importantly, research often uses self-reported symptoms, rather than patients who have formally met diagnostic criteria.
Historically, the focus has been on depression. However, elevated symptoms of anxiety are much more common than elevated symptoms of depression.
It is important to make the distinction between “Generalized Anxiety,” and “Heart-Focused Anxiety.”Heart-Focused Anxiety: symptoms of anxiety directly related to having a heart condition, such as fear of appointments / worry about a decline in health status, getting an ICD, preparing for surgery, transplants, or having a shortened life expectancy, etc. This may also include a significant component of he...
230. Case Report: A Tight Spot On The Right – Cleveland Clinic
Aug 31, 2022
CardioNerds (Amit Goyal and Dan Ambinder) join Dr. Radi Zinoviev, Dr. Josh Cohen, and Dr. Tiffany Dong (CardioNerds Ambassador) from the Cleveland Clinic for a day on Edgewater beach. They discuss the following case of the evaluation and management of prosthetic tricuspid valve stenosis in a patient with a history of Ebstein Anomaly. The expert commentary and review (ECPR) is provided by Dr. Jay Ramchand, staff cardiologist with expertise in multimodality cardiovascular imaging at the Cleveland Clinic.
Jump to: Case media - Case teaching - References
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Case Media
CXR
ECG
TTE
RHC
Final TTE
TTE 1
TTE 2
TTE 3
Follow up TTE 1
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Episode Schematics & Teaching
Pearls - Tricuspid Valve Stenosis
Tricuspid stenosis is uncommon (<1% of the US population) and thus we have a lack of evidence as well as guideline recommendations.While there are no official diagnostic criteria for severe tricuspid stenosis, some echocardiographic features include flow acceleration across the valve, a mean pressure gradient of ≥ 5mmHg and an inflow VTI of > 60cm.Structural findings that support the presence of severe tricuspid stenosis include a moderately dilated RA and a dilated IVC, though these are not specific.Right heart catheterization hemodynamics that support tricuspid stenosis include a high right atrial pressure and gradual “y” descent.Bioprosthetic tricuspid valves are generally favored over mechanical valves due to risk of thrombosis and longevity of these valves in the tricuspid position.
Notes - Tricuspid Valve Stenosis
What are causes of tricuspid stenosis?
Causes of tricuspid stenosis can be divided into congenital and acquired causes. Congenital causes include tricuspid atresia or stenosis. Acquired causes include rheumatic heart disease, carcinoid syndrome, endocarditis, prior radiation, or fibrosis from endomyocardial procedures or placement of electrical leads. Rheumatic heart disease is the most common cause of tricuspid stenosis and is usually associated with mitral valvulopathy.
What are the symptoms and physical exam findings of tricuspid stenosis?
Findings revolve around right sided congestion or heart failure symptoms such as peripheral edema, abdominal distension with ascites, hepatomegaly, and jugular venous distension. When examining the jugular vein, you may see prominent a-waves and an almost absent or slow y descent reflective of delayed emptying of the right atrium (in the absence of tricuspid regurgitation). The murmur of tricuspid stenosis includes an opening snap and low diastolic murmur at the left lower sternal border with inspiratory accentuation. Patients may also report fatigue due to decreased cardiac output from obstruction.
On echocardiography, what are the features supportive of severe tricuspid stenosis?
Qualitatively, the leaflets may be thickened with reduced mobility and there may be diastolic dooming of the valve. Doppler may show high gradients of ≥ 5 mmHg, which may be elevated if there is coexisting tricuspid regurgitation and lower with decreased cardiac output. Associated structural changes include dilated right atrium and inferior vena cava.
What is expected on right heart catheterization for tricuspid stenosis?
Assuming the patient remains in sinus rhythm, patients with tricuspid stenosis would display high right atrial pressures and a gradual “y” descent. A diastolic gradient may be measured with dual catheters in the right atrium and the right ventricle.
What are the treatment options for tricuspid stenosis?
Medical management of tricuspid stenosis includes diuretics and addressing the underlying cause.
229. CardioNerds Rounds: Challenging Cases – Atrial Fibrillation with Dr. Hugh Calkins
Aug 23, 2022
It’s another session of CardioNerds Rounds! In these rounds, Dr. Stephanie Fuentes (EP FIT at Houston Methodist) joins Dr. Hugh Calkins (Professor of Medicine and Director of the Electrophysiology Laboratory and Arrhythmia Service at Johns Hopkins Hospital) to discuss the nuances of atrial fibrillation (AF) management through challenging cases. As an author of several guideline and expert consensus statements in the management of AF and renowned clinician, educator, and researcher, Dr. Calkins gives us many pearls on the management of AF, so don’t miss these #CardsRounds!
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
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Show notes - Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins
Case #1 Synopsis:
A woman in her mid-60s presents with symptomatic paroxysmal atrial fibrillation (AF). An echocardiogram has demonstrated that she has a structurally normal heart. Her primary care doctor had started Metoprolol 50 mg twice a day but she has remained symptomatic. In office, an EKG confirms AF, but she converts to sinus while there. She is seeking advice to prevent further episodes and in general wants to avoid additional medications
Case #2 Takeaways
We discussed several potential options for treatment. Amongst the first things we discussed was amiodarone. In a patient of this nature without structural heart disease and under the age of 70, Dr. Calkins discussed that he would probably consider amiodarone as a 2nd line option. While amiodarone may be effective in maintaining sinus rhythm in comparison to other antiarrhythmic medications like sotalol, flecainide, and propafenone, it does have significant toxicity.If antiarrhythmic drugs (AAD) were to be considered, we also discussed the options of dofetilide versus sotalol. Dofetilide typically requires inpatient initiation due to the risk of QT prolongation and Torsades. Since women tend to have longer corrected QT (QTc) intervals, high dose dofetilide may be more proarrhythmogenic in women. Though, Dr. Calkins noted that many patients don’t tolerate sotalol due to fatigue and generally dofetilide is well tolerated.When it comes to the “pill in the pocket” approach, Dr. Calkins noted that its utility is more so in patients with persistent AF that is known to not stop on its own. For instance, an individual who has AF a few times a year that is persistent may benefit from flecainide or propafenone (“in the pocket”) instead of being brought in for an electrical cardioversion. In this scenario, the first time one of these agents is used, the patient ought to be closely monitored. For our patient, her episodes were too frequent and self-terminating for a “pill in the pocket” approach to be effective.Current guideline recommendations for catheter ablation include a Class IA recommendation for patients with paroxysmal AF refractory to AADs, and a Class IIA recommendation as first-line therapy for patients with paroxysmal AF.In the 2020 ESC Atrial Fibrillation Guidelines, catheter ablation is given a Class IA recommendation to improve symptoms of AF recurrences in patients who have failed or are intolerant of one Class I or III AADs. For patients who have failed or have been intolerant of beta blocker alone for rhythm control,
228. Narratives in Cardiology: Radiation Safety & Women in Interventional Cardiology with Dr. Sheila Sahni – New Jersey Chapter
Aug 17, 2022
In this episode, Daniel Ambinder (CardioNerds Co-Founder), Dr. Gurleen Kaur (Director of CardioNerds Internship and medicine resident at Brigham and Women’s Hospital), Dr. Eunice Dugan (Cardiology fellow at Cleveland Clinic) and Dr. Zarina Sharalaya (Interventional and Structural Cardiologist at North Texas Heart) learn from the Dr. Sheila Sahni (Interventional Cardiologist and Director of The Women’s Heart Program at The Sahni Heart Center) regarding radiation safety in the cath lab and methods of reducing radiation exposure to the operator. She also discusses radiation safety for the pregnant interventional cardiologist and how to safely manage pregnancy during the gestational period. We hear her inspirational journey as a female interventional cardiologist and her experience in starting the Women’s Heart Program at Sahni Heart Center. Special message by Dr. Jeff Lander, New Jersey ACC Chapter Governor. Audio editing by CardioNerds Academy Intern, Pace Wetstein.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • Production Team
Claim free CME just for enjoying this episode! There are no relevant disclosures for this episode.
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Video version - Radiation Safety & Women in Interventional Cardiology with Dr. Sheila Sahni
https://youtu.be/iIwnsu6qJ4k
Tweetorial - Radiation Safety & Women in Interventional Cardiology with Dr. Sheila Sahni
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Quoatables - Radiation Safety & Women in Interventional Cardiology with Dr. Sheila Sahni
“Having anyone who can believe in you when you are really passionate about something is really all you need… the passion is what’s going to carry you through. It’s not about being male or female or pregnant or not pregnant, it’s about what you love to do and how can you master it.”
“Our careers can wait, but family planning cannot. If you are fortunate enough to have the opportunity to start a family even if it’s during your training, you should”.
Notes - Radiation Safety & Women in Interventional Cardiology with Dr. Sheila Sahni
What are procedural techniques to utilize during a heart catheterization to reduce radiation exposure to the operator?
Decrease number and length of cine acquisitions and fluoroscopy timeDecrease the frame rate - halving the frame rate reduces radiation dose by 50%Decrease the distance between the image intensifier and the patientLimit steep LAO angulationsApply collimation as much as possible which reduces overall patient dose and scatter radiationLimit digital magnification which can increase skin dose exposure by 50%
What are the important dose limits to consider for a pregnant female and her fetus in the cath lab?
The US Nuclear Regulatory Commission (NRC) regulatory equivalent dose limit is 5mSv during the entire pregnancy of the declared pregnant woman.The annual natural background radiation dose in the US is 3mSv.The average under-lead dose to a working pregnant interventionalist over the entire gestation is ~0.3mSv.The fetus of a working pregnant interventionalist is estimated to ...
227. CCC: Positive Pressure Ventilation in the CICU with Dr. Sam Brusca, Dr. Chris Barnett, and Dr. Burton Lee
Aug 14, 2022
The modern CICU has evolved to include patients with complex pulmonary mechanics requiring more non-invasive and mechanical ventilation. Series co-chairs Dr. Eunice Dugan and Dr. Karan Desai along with CardioNerds Co-founder Dr. Amit Goyal were joined by FIT lead, Dr. Sam Brusca, who has completed his NIH Critical Care and UCSF Cardiology fellow and currently faculty at USCF. We were fortunate enough to have two expert discussants: Dr. Burton Lee, Head of Medical Education and Global Critical Care within the National Institutes of Health Critical Care Medicine Department and master clinician educator with the ATS Scholar’s Critical Care for Non-Intensivists program, and Dr. Chris Barnett, ACC Critical Care Cardiology council member and Section Chair of Critical Care Cardiology at UCSF. In this episode, these experts discuss the basics of mechanical ventilation, including the physiology/pathophysiology of negative and positive pressure breathing, a review of ventilator modes, and a framework for outlining the goals of mechanical ventilation. They proceed to apply these principles to patients in the CICU, specifically focusing on patients with RV predominant failure due to pulmonary hypertension and patients with LV predominant failure. Audio editing by CardioNerds Academy Intern, student doctor, Shivani Reddy.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Production Team
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Pearls and Quotes - Positive Pressure Ventilation in the CICU
Respiratory distress, during spontaneous negative pressure breathing can lead to high transpulmonary pressures and potentially large tidal volumes. This will increase both RV afterload (by increasing pulmonary vascular resistance) and LV afterload (by increasing LV wall stress).
An analogy for the impact of negative pleural pressure during spontaneous respiration on LV function is that of a person jumping over a hurdle. The height of the hurdle does not increase, but the ground starts to sink, so it is still harder to jump over.
Intubation in patients with right ventricular failure is a tenuous situation, especially in patients with chronic RV failure and remodeling (increased RV thickness, perfusion predominantly during diastole, RV pressure near or higher than systemic pressure). The key tenant to safe intubation is avoiding hypotension, utilizing induction agents such as ketamine or etomidate, infusing pressors, and potentially even performing awake intubations.
Non-invasive positive pressure ventilation in HFrEF has hemodynamic effects similar to a cocktail of IV inotropes, dilators, and diuretics. CPAP decreases pulmonary capillary wedge pressure (LV preload), decreases systemic vascular resistance (afterload), and increases cardiac output.
Airway pressure during mechanical ventilation is based on the “equation of motion”: Pressure = Volume/Compliance + Flow*Resistance + PEEP.
Our goals of oxygenation on mechanical ventilation include achieving acceptable PaO2/Sat with the lowest FiO2 possible (avoiding oxygen toxicity) and optimal PEEP (which increases oxygenation but can have detrimental impact on cardiac output)
Our goals of ventilation on mechanical ventilation include achieving acceptable pH and PaCO2 while preventing ventilator induced lung injury and avoiding auto-PEEP. We prevent lung injury by reducing tidal volume (ideally <8cc/kg, plateau pressure < 30 cmH20, driving pressure < 15 cmH20) and auto-peep by reducing respiratory rate (and allowin...
226. Case Report: Fall from Grace – A Case of Pulmonary Embolism – Massachusetts General Hospital
Aug 04, 2022
CardioNerds (Amit and Dan) join join Dr. Andrew Dicks (Vascular medicine physician at Prisma Health, former fellow at Mass General Vascular) and Dr. Prateek Sharma (Vascular interventional & medicine fellow at MGH) for an ice-cold drinks at the Esplanade in Boston, MA to discuss a case about a patient who developed a pulmonary embolism and masterfully discuss the diagnosis and management of of pulmonary emboli. Dr. Ido Weinberg (Director, Vascular Medicine Fellowship at MGH) provides the ECPR for this episode.
Case Abstract: A 59-year-old Spanish-speaking man with no significant past medical history presents after falling 15-20 feet from a ladder and landing on his back. He was found to have an L1 fracture and left radial fracture and underwent T12-L2 fusion with neurosurgery on hospital day 1 and ORIF of left radial fracture with orthopedic surgery on hospital day 2. On hospital day 5, he develops acute onset tachycardia with HR in the 130s bpm with new O2 requirement associated with mild shortness of breath at rest without any chest discomfort. His labs were notable for an elevated troponin and proBNP. He underwent CTPA which demonstrated acute bilateral occlusive pulmonary emboli (PE) extending in the right and left main pulmonary arteries. TTE demonstrated right ventricle dilation. The patient was started on a heparin infusion and a PE response team (PERT) meeting was held to discuss treatment options. Given recent surgery, use of thrombolytic therapy was felt to be too risky and thus he was taken for percutaneous thrombectomy in the cath lab. PA pressure prior to intervention was 51/21 mmHg. The patient underwent suction thromboembelectomy with the Flow Triever device with extraction of thrombus and improvement in PA pressure to 19/11 mmHg. He was treated with anticoagulation thereafter and discharged home two days after the procedure.
Jump to: Case media - Case teaching - References
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Case Media
Acute bilateral occlusive and nonocclusive pulmonary emboli extending from the right and left main pulmonary arteries to the lobar and segmental arteries of all the lobes. Moderate right heart strain including the right atrium and the right ventricle. RV/LV ratio > 1.0.
Right ventricular cavity is dilated (RV size at the base measures to 45mm). Right ventricular systolic function is moderately decreased. Right ventricular free wall is hypokinetic with sparing of the right ventricular apex consistent with acute right ventricular strain
Pulmonary angiography demonstrated extensive proximal bilateral PEs
Caption: Post-procedure TTE demonstrated resolution of RV strain with normalization of RV size and function.
Episode Schematics & Teaching
Pearls
While there are markers to suggest PE, such as ECG findings or evidence of RV dilatation, a PE cannot be confirmed without imaging.Elevation of cardiac biomarkers and evidence of RV dysfunction are used to risk stratify PE, not the degree of thrombus burden or locale of thrombus.Enoxaparin is the preferred anticoagulant to initiate at time of PE diagnosis if comorbidities allow.Optimal treatment of intermediate risk PE remains uncertain as there is little data about long-term outcomes. Aggressive treatment should be used judiciously and chosen on a case-by-case basis.PE response teams (PERT) allow for multidisciplinary expert opinion in the face of scarce evidence to determine what is felt to be the best management strategy.
Notes
1. What is a PERT team and why is it helpful?
We have several tools and approaches for the management of PE. There are also many subspecialities involved in the care of patients with PE, including vascular medicine,
225. ACHD: Advanced Heart Failure Therapies (MCS/HT) Among ACHD Patients with Dr. Rafael Alonso-Gonzalez
Jul 31, 2022
CardioNerds (Daniel Ambinder) and ACHD series co-chair Dr. Dan Clark discuss advanced heart failure therapies including mechanical circulatory support (MCS) and heart transplantation (HT) in patients with adult congenital heart disease (ACHD) with Dr. Rafael Alonso-Gonzalez, cardiologist and director of Adult Congenital Heart Disease program at the University of Toronto and ACHD fellow Dr. Andy Pistner (University of Washington). They cover epidemiology of heart failure in ACHD, outcomes after HT, unique challenges of HT in this population, impact of allocation policies on access to transplantation, and regionalization of advanced heart failure care. They also discuss a practical approach to advanced heart failure therapy evaluation in ACHD. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Advanced Heart Failure Therapies (MCS/HT) Among ACHD Patients
Heart failure is a major comorbidity and the leading cause of death in adults with congenital heart disease.Identification of advanced heart failure in ACHD is challenging. ACHD patients do not always self-identify exercise limitations or exertional dyspnea. Cardiopulmonary exercise testing is a useful tool in evaluating these patients.Patients with ACHD awaiting heart transplantation are less likely than non-ACHD patients to receive a heart transplant, and ACHD patients have an increased risk of death or delisting while awaiting heart transplantation.Evaluation of transplant candidacy and potential need for multi-organ transplantation in complex congenital heart disease (i.e., Fontan palliation) requires a multidisciplinary approach.Regionalization of care improves outcomes for ACHD patients with advanced heart failure. High volume transplant centers have better early survival for ACHD patients after heart transplant, and the highest volume ACHD transplant centers in each UNOS region have better early survival.
Show notes - Advanced Heart Failure Therapies (MCS/HT) Among ACHD Patients
1. How many ACHD patients have heart failure?
Patients with ACHD are a large and heterogeneous group. The signs and symptoms of heart failure vary widely depending on the underlying congenital heart disease. Patients with D-transposition of the great arteries repaired with an arterial switch operation have low rates of heart failure (~3%)1 compared to those patients Fontan palliation for single ventricle physiology (40%)2. Heart failure is the leading cause of death in patients with ACHD3,4.
2. How many patients with ACHD end up receiving a heart transplant or mechanical circulatory support?
Heart transplantation for congenital heart disease in adults has been increasing in frequency since the late 1980s. Between 2010 and 2012, this accounted for 4% of all adult heart transplants in the United States5. This represents a small fraction compared to the number of adults who die due to complications of heart failure ...
224. Atrial Fibrillation: Assessment of Stroke & Bleeding Risk with Dr. Elaine Hylek
Jul 26, 2022
CardioNerds (Amit Goyal), Dr. Colin Blumenthal (CardioNerds Academy House Faculty Leader and FIT at the University of Pennsylvania), and Dr. Anjali Wagle (CardioNerds Ambassador and FIT at Johns Hopkins University), discuss the baseline assessment of stroke and bleeding risk in patients with atrial fibrillation (AF) with Dr. Elaine Hylek. Dr. Hylek is a professor of medicine at the Boston University School of Medicine and is the Director of the Thrombosis and Anticoagulation Service at Boston Medical Center. Stroke is a potentially devastating and preventable complication of AF. Understanding the balance between stroke and bleeding risk is crucial in determining who should be on anticoagulation. Join us to discuss this topic! In the next episode of the series, we will discuss situational risk assessment in the context of peri-cardioversion, peri-procedural status, triggered atrial fibrillation, and more. Audio editing by CardioNerds Academy Intern, Pace Wetstein.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This series is supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
We have collaborated with VCU Health to provide CME. Claim free CME here!
Disclosures: Dr. Hylek discloses grant and research support from Medtronic and Janssen, and honoraria and/or consulting fees from Boehringer Ingelheim, and Bayer.
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Pearls and Quotes - Atrial Fibrillation: Assessment of Stroke & Bleeding Risk
The CHA2DS2-VASc should be used to determine stroke risk in all patients. It was updated from the CHADS2 score to better separate patients into high and low risk and a score of 0 has a very low risk of a stroke.
Understanding a given model’s derivation is key to application for any risk model. Understanding who was and was not included when a risk score was derived helps determine how to clinically use it. For example, mechanical valves, hypertrophic cardiomyopathy, cardiac amyloidosis, and moderate to severe MS were all excluded or poorly represented and should receive AC in AF regardless of CV.
The HAS-BLED score should be used to identify modifiable risk factors for bleeding and address them. It is less useful to determine when we should stop AC. Factors that go into the score are dynamic and the intention was to alert the provider of potentially modifiable factors that could be addressed to lower bleeding risk (such as better BP control).
Fear the clot. Patients should be on AC unless there is a serious contraindication as embolic strokes can be devastating with a high mortality (~24% mortality at 30 days)
“What am I saying by not writing the prescription... I am saying that it’s OK to have an ischemic stroke.” Survey data shows that patients are willing to experience 3.5 GI bleeds on average before 1 stroke, so favoring AC is often a patient centered approach
Notes - Atrial Fibrillation: Assessment of Stroke & Bleeding Risk
Notes drafted by Dr. Anjali Wagle
1. Why do strokes happen in atrial fibrillation? Why is reducing stroke risk so important?
Atrial fibrillation is associated with a significantly increased risk of stroke. The mortality of strokes related to AF have been estimated to be around 25% at 30 days in early studies which included either persistent or permanent AF, though of note, these studied were biased towards larger strokes since the diagnosis was based on physical exam and not high resolution imaging.
223. CCC: Approach to Acute Myocardial Infarction Cardiogenic Shock with Dr. Venu Menon
Jul 17, 2022
With the advent and rapid evolution of contemporary percutaneous coronary intervention (PCI), the early invasive management of acute myocardial infarction (AMI) has become a mainstay in therapy with significant impact on patient outcomes. However, despite modern advances in technology and system-based practices, AMI presenting with cardiogenic shock (CS) continues to portend a high risk of morbidity and mortality. Few randomized controlled clinical trials are available to guide decision-making in this uniquely challenging patient population. Understanding the pathophysiologic mechanism by which injury occurs and propagates the shock cycle can be instrumental in selecting an appropriate strategy for revascularization and left ventricular unloading. In this episode we are joined by Dr. Venu Menon, The Mehdi Razavi Endowed Chair and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine, section head of clinical cardiology, fellowship program director, and director of the Cardiac intensive care unit at the Cleveland Clinic. Dr. Menon shares his wealth of knowledge and experience to help us review the contemporary data available for AMI CS management in a case-based discussion. We are also joined by Dr. Priya Kothapalli, star chief fellow and future interventionalist from University of Texas at Austin, series co-chair Dr. Yoav Karpenshif, and CardioNerds Co-founders Amit Goyal and Daniel Ambinder. Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls and Quotes - Approach to Acute Myocardial Infarction Cardiogenic Shock with Dr. Venu Menon
The H&P does matter! Age, location of infarction, heart rate, systolic blood pressure, and heart failure symptoms all carry weight in determining prognosis and risk of mortality.Define functional status, comorbid conditions, and life expectancy to help guide clinical decision-making. Do a quick bedside echocardiogram if possible to elucidate the predominant mechanism driving CS and rule out mechanical complications.Act with urgency! Get to the catheterization lab to characterize coronary anatomy and revascularize the culprit vessel as soon as possible.Minimize/avoid the use of vasopressors; if needed, wean as quickly as possible to avoid worsening myocardial ischemia. Consider mechanical circulatory support early!Despite dramatic advances in AMI management, data is limited in AMI CS management. Ask the important questions, get involved in the scientific inquiry as a trainee!
Show notes - Approach to Acute Myocardial Infarction Cardiogenic Shock with Dr. Venu Menon
1. Why is it important to recognize AMI complicated by CS?
AMI CS occurs in 7-10% of patients presenting with AMI and has a higher prevalence among elderly patients.The SHOCK trial (1999) showed significant survival benefit at 6 months with early revascularization with balloon angioplasty compared to medical therapy alone in AMI CS.Registry data suggests that early revascularization is beneficial in AMI CS even in elderly patients. Decision-making should be guided using a holistic view of the patient’s overall biology.Despite advances in revascularization techniques and availability of mechanical support, AMI CS portends a 40-45% risk of 30-day mortality in the modern era.Significant variation in management strategy exists between centers and data to guide decision-making is li...
222. CardioNerds Rounds: Challenging Cases – Nuances in Pulmonary Hypertension Management with Dr. Ryan Tedford
Jul 14, 2022
It’s another session of CardioNerds Rounds! In these rounds, Co-Chair, Dr. Karan Desai (previous FIT at the University of Maryland Medical Center, and now faculty at Johns Hopkins) joins Dr. Ryan Tedford (Professor of Medicine and Chief of Heart Failure and Medical Directory of Cardiac Transplantation at the Medical University of South Carolina in Charleston, SC) to discuss the nuances of managing pulmonary hypertension in the setting of left-sided heart disease. Dr. Tedford is an internationally-recognized clinical researcher, educator, clinician and mentor, with research focuses that include the hemodynamic assessment of the right ventricle and its interaction with the pulmonary circulation and left heart.
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Cases discussed and Show Notes • References • Production Team
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Show notes - Challenging Cases - Nuances in Pulmonary Hypertension Management with Dr. Ryan Tedford
Case #1 Synopsis:
A woman in her late 30s presented to the hospital with 4 weeks of worsening dyspnea. Her history includes dilated non-ischemic cardiomyopathy diagnosed in the setting of a VT arrest around 10 years prior. Over the past 10 years she has been on guideline-directed medical therapy with symptoms that had been relatively controlled (characterized as NYHA Class II), but without objective improvement in her LV dimensions or ejection fraction (LVEF 15-20% by TTE and CMR and LVIDd at 6.8 cm). Over the past few months she had been noting decreased exercise tolerance, worsening orthopnea, and episodes of symptomatic hypotension at home. When she arrived to the hospital, she presented with BP 95/70 mmHg, increased respiratory effort, congestion and an overall profile consistent with SCAI Stage C-HF shock. In the case, we go through the hemodynamics at various points during her hospitalization and discuss options for management including medical therapy and mechanical support. The patient was eventually bridged to transplant with an Impella 5.5.
Initial Hemodynamics
Right Atrium (RA) Pressure Tracing:
Right Ventricle (RV) Pressure Tracing:
Pulmonary Artery (PA) Pressure Tracing:
Pulmonary Capillary Wedge Pressure (PCWP) Tracing:
Case 1 Rounding Pearls
One of the first points that Dr. Tedford made was thinking about our classic frameworks of characterizing acute decompensated heart failure, specifically the “Stevenson” classification developed by Dr. Lynne Stevenson that phenotypes patients along two axes: congestion (wet or dry) and perfusion (warm or cold). Dr. Tedford cautioned that young patients may not fit into these classic boxes well, and that a normal lactate should not re-assure the clinician that perfusion is normal.In reviewing the waveforms, Dr. Tedford took a moment to note that besides just recording the absolute values of the pressures transduced in each chamber or vessel, it is critical to understand the morphology of the tracings themselves. For instance, with the RA pressure tracing above, there is no respiratory variation in the mean pressure. This is essentially a “resting Kussmaul’s sign,” which is typically indicative of significant RV dysfunction. Thus, even though our echocardiogram in this case did not necessarily show a significantly dilated RV with mildly reduced longitudinal function (T...
221. Guidelines: 2021 ESC Cardiovascular Prevention – Question #18 with Dr. Jaideep Patel
Jul 12, 2022
The following question refers to Section 6.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by Houston Methodist medicine resident Dr. Najah Khan, and then by expert faculty Dr. Jaideep Patel.
Dr. Patel recently graduated from Virginia Commonwealth University cardiology fellowship and is now a preventive cardiologist at the Johns Hopkins Hospital.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #18
A 60-year-old Black woman with a history of hypertension and heart failure with reduced ejection fraction (EF 40%) presents to clinic for follow-up. She is currently doing well with NYHA class II symptoms. She is taking carvedilol 25 mg BID, sacubitril/valsartan 97/103 mg BID, and spironolactone 25 mg daily, all of which have been well tolerated. In clinic, her BP is 125/80 mmHg, and her HR is 55 bpm. Routine labs are within normal limits including Cr of 1.0, K of 4.0, and HbA1c of 6.0. What is the most appropriate next step in her management?
A. No change in management
B. Reduce beta blocker
C. Add an SGLT2 inhibitor (dapagliflozin or empagliflozin)
D. Add vericiguat
E. Add hydralazine/isosorbide dinitrate
Answer #18
The correct answer is C – Add an SGLT2 inhibitor (dapagliflozin or empagliflozin)
For patients with symptomatic HFrEF, neurohormonal antagonists (ACEi, ARB, ARNI; BB; MRA) improve survival and reduce the risk of HF hospitalization. This patient is already on these agents. The addition of an SGLT2 inhibitor on top of neurohormonal blockade reduces the risk of CV death and worsening HF in patients with symptomatic HFrEF and is the next best step for this patient (Class I, LOE A).
Vericiguat may be considered in patients with symptomatic HFrEF with HF worsening despite already being on maximally tolerated neurohormonal blockade (Class IIb, LOE B), but first-line therapies should be started first.
Hydralazine/Isosorbide dinitrate should be considered in self-identified Black patients or people who have EF ≤ 35% or <45% with dilated LV with class III-IV symptoms despite maximally tolerated neurohormonal blockade (Class IIa, LOE B), but is not the next best step here.
She is tolerating the beta blocker without adverse effects so there is no reason to decrease the dosage.
Main Takeaway
In patients with symptomatic HFrEF (EF ≤ 40%), SGLT2 inhibitors are considered first line therapy in addition to ACE-I/ARB/ARNI, BB, and MRAs to reduce the risk of HF hospitalization and death. Importantly this is irrespective of presence of diabetes.
Guideline Location
Section 6.2, page 3295-3296
Figure 13 page 3278; recommendation table page 3279.
CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series
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220. Guidelines: 2021 ESC Cardiovascular Prevention – Question #17 with Dr. Melissa Tracy
Jul 07, 2022
The following question refers to Section 4.9 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD fellow Dr. Patrick Azcarate, and then by expert faculty Dr. Melissa Tracy.
Dr. Tracy is a preventive cardiologist, former Director of the Echocardiography Lab, Director of Cardiac Rehabilitation, and solid organ transplant cardiologist at Rush University.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #17
A 74-year-old man with a history of hypertension, chronic kidney disease, and gastroesophageal reflux presents with chest pain and is found to have an NSTEMI due to an obstructive lesion in the proximal LAD. One drug-eluting stent is placed, and he is started on dual antiplatelet therapy with aspirin and clopidogrel. He is concerned about the risk of bleeding from his gastrointestinal tract. What would you recommend to reduce his risk of bleeding?
A. Lansoprazole, a proton pump inhibitor
B. Famotidine, a histamine-2 blocker
C. Calcium carbonate, an antacid
D. None, proton pump inhibitors are contraindicated.
Answer #17
The correct answer is A.
The ESC recommends that patients at high risk for GI bleeding who are receiving antiplatelet therapy take proton pump inhibitors (Class I, LOE A). High risk for bleeding includes patients who are age ≥65, history of peptic ulcer disease, Helicobacter pylori infection, dyspepsia or GERD symptoms, chronic renal failure, diabetes mellitus, and concomitant use of other antiplatelet agents, anticoagulants, nonsteroidal anti-inflammatory drugs, or steroids.
Coadministration of proton pump inhibitors that specifically inhibit CYP2C19 (omeprazole or esomeprazole) may reduce the pharmacodynamic response to clopidogrel. Although this interaction has not been shown to affect the risk of ischemic events, coadministration of omeprazole or esomeprazole with clopidogrel is not recommended.
Main Takeaway
In patients with high gastrointestinal bleeding risk who are receiving antiplatelet therapy, proton pump inhibitors are recommended. Omeprazole and esomeprazole may reduce the efficacy of clopidogrel and should not be used concomitantly with clopidogrel.
Guideline Location
Section 4.9.3, Page 3291
Figure 13 page 3278; recommendation table page 3279.
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219. Guidelines: 2021 ESC Cardiovascular Prevention – Question #16 with Dr. Roger Blumenthal
Jul 05, 2022
The following question refers to Section 4.6 and Figure 13 of the 2021 ESC CV Prevention Guidelines. The question is asked by student doctor Shivani Reddy, answered first by NP Carol Patrick, and then by expert faculty Dr. Roger Blumenthal.
Dr. Roger Blumenthal is professor of medicine at Johns Hopkins where he is Director of the Ciccarone Center for the Prevention of Cardiovascular Disease. He was instrumental in developing the 2018 ACC/AHA CV Prevention Guidelines.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #16
True or False: For patients with established ASCVD, secondary prevention entails adding a PCSK9 inhibitor if goal LDL is not met on maximum tolerated doses of a statin and ezetimibe.
Answer #16
The correct answer is True.
The ultimate on-treatment LDL-C goal of <55 mg/dL (<1.4 mmol/L) and a reduction of at least ≥50% from baseline should be considered for primary prevention of persons <70 years of age at very high risk (Class IIa) and in those with established ASCVD (Class I).
It is recommended that a high-intensity statin is prescribed up to the highest tolerated dose to reach these LDL-C goals (Class I).
The combination of statin with ezetimibe brings a benefit that is in line with meta-analyses showing that LDL-C reduction has benefits independent of the approach used. The beneficial effect of ezetimibe is also supported by genetic studies. Together, these data support the position that ezetimibe should be considered as second-line therapy, either on top of statins when the therapeutic goal is not achieved (Class I), or when a statin cannot be prescribed (Class IIa).
PCSK9 inhibitors (monoclonal antibodies to PCSK9) decrease LDL-C by up to 60%, either as monotherapy or in addition to the maximum tolerated dose of statin and/or other lipid-lowering therapies, such as ezetimibe. Their efficacy appears to be largely independent of background therapy. Among patients in whom statins cannot be prescribed, PCSK9 inhibition reduced LDL-C levels when administered in combination with ezetimibe. Both alirocumab and evolocumab effectively lower LDL-C levels in patients who are at high or very high CVD risk, including those with DM, with a large reduction in future ASCVD events.
Therefore, for those who do not meet LDL-C goals with maximally tolerated doses of both a statin and ezetimibe, combination therapy including a PCSK9 inhibitor may be considered for primary prevention of patients at very high risk but without familial hypercholesterolemia (Class IIa) and is recommended for secondary prevention for those with established ASCVD (Class I). In addition, for very-high-risk FH patients (that is, with ASCVD or with another major risk factor) who do not achieve their goals on a maximum tolerated dose of a statin and ezetimibe, combination therapy including a PCSK9 inhibitor is recommended (Class I).
Main Takeaway
Statins, ezetimibe, and PCSK9 inhibitors should be used in a stepwise approach to achieve target lipid lowering goals in accordance with their risk profile.
Guideline Location
Page 3279, Sections 4.6.3.1.4, 4.6.3.1.5
Figure 13 page 3278; recommendation table page 3279.
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218. Guidelines: 2021 ESC Cardiovascular Prevention – Question #15 with Dr. Kim Williams
Jul 05, 2022
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon and then by expert faculty Dr. Kim Williams.
Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016).
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #15
Your patient mentions that she drinks “several” cups of coffee during the day. She also describes having a soda daily with lunch and occasionally a glass of wine with dinner. Which of the following recommendations is appropriate?
A. Coffee consumption is not harmful and may even be beneficial, regardless of the number of drinks per day.
B. Drinking two glasses of wine/day is safe from a cardiovascular prevention standpoint.
C. Soft drinks (and other sugar-sweetened beverages) must be discouraged.
D. None of the above
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Answer #15
The correct answer is C. Soft drinks (and other sugar-sweetened beverages) must be discouraged.
Sugar-sweetened beverages have been associated with a higher risk of CAD and all-cause mortality. The ESC guidelines give a class I recommendation for restriction of free sugar consumption (in particular sugar-sweetened beverages) to a maximum of 10% of energy intake. This is a class IIa recommendation in the ACC/AHA guidelines.
Choice A is incorrect because: the consumption of nine or more drinks a day of non-filtered coffee (such as boiled, Greek, and Turkish coffee and some espresso coffees) may be associated with an up to 25% increased risk of ASCVD mortality. Moderate coffee consumption (3-4 cups per day) is probably not harmful, and perhaps even moderately beneficial.
Choice B is incorrect: It is a class I recommendation to restrict alcohol consumption to a maximum of 100 g per week. The standard drink in the US contains 14 g of alcohol, so 100 mg of alcohol translate to:
o 84 ounces of beer (5% alcohol)
o Or 56 – 63 ounces of malt liquor (75% alcohol) or
o Or 35 ounces of wine (12% alcohol) or ONE 5 fl oz glass of wine/day.
o Or 31.5 ounces of distilled spirits (40% alcohol).
The ACC/AHA guidelines recommended limiting alcohol consumption only for the management of hypertension to: ≤2 drinks daily for men and: ≤1 drink daily for women.
Main Takeaway
The main takeaway: ASCVD risk reduction can be achieved by restricting sugar-sweetened beverages to a maximum of 10% of energy intake.
Guideline Location
Section 4.3.2, Page 3271
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217. Guidelines: 2021 ESC Cardiovascular Prevention – Question #14 with Dr. Allison Bailey
Jul 01, 2022
The following question refers to Sections 3.3-3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Allison Bailey.
Dr. Bailey is a cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology's Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #14
Ms. Soya M. Alone is a 70-year-old woman of Bangladeshi ethnicity with a history of anxiety and depression. She currently lives at home by herself, does not have many friends and family that live nearby, and has had a tough year emotionally after the passing of her husband. She spends most of her time in bed with low daily physical activity and has experienced more weakness and exhaustion over the past year along with loss of muscle mass. Which of the following are potential risk modifiers in this patient when considering her risk for CVD?A. Bangladeshi ethnicity B. Psychosocial factorsC. Frailty D. History of anxiety and depressionE. All of the above
Answer #14
The correct answer is E – All of the above.Traditional 10-year CVD risk scores do not perform adequately in all ethnicities. Therefore, multiplication of calculated risk by relative risk for specific ethnic subgroups should be considered (Class IIa, LOE B). Individuals from South Asia have higher CVD rates. The ESC guidelines recommend using a correction factor by multiplying the predicted risk by 1.3 for Indians and Bangladeshis, and 1.7 for Pakistanis. These correction factors are derived from data from QRISK3. In the UK, the QRISK calculator algorithm has been derived and validated in 2.3 million people to estimate CVD risk in different ethnic groups and unlike other calculators, it counts South Asian origins as an additional risk factor. The reasons for such differences remain inadequately studied, as do the risks associated with other ethnic backgrounds. Barriers to developing accurate risk prediction tools include the wide heterogeneity amongst the population.The 2019 ACC/AHA guidelines also list high-risk race/ethnicities such as South Asian ancestry as a risk-enhancing factor. However, there is no separate pooled cohort equation for different ethnicities, and consideration should be given that the pooled cohort equations will underestimate ASCVD risk in South Asians.Psychosocial stress including loneliness and critical life events are associated, in a dose-response pattern, with the development and progression of ASCVD, with relative risks between 1.2 and 2.0. Conversely, indicators of mental health, such as optimism and a strong sense of purpose, are associated with lower risk. While there is not a specific way proposed by the guidelines for psychosocial factors to improve risk classification, it is important to screen patients with ASCVD for psychological stress, and clinicians should attend to somatic and emotional causes of symptoms as well. The ESC guidelines give a Class IIa (LOE B) recommendation for assessment of stress symptoms and psychosocial stressors.This patient should also be formally screened for frailty, which is not the same as aging but includes factors such as slowness, weakness, low physical activity, exhaustion and shrinking, and makes her more vulnerable to the effect of stressors and is a risk factor for both high CV and non-CV morbidity and mortality. However, the ability of frailty measures to improve CVD risk prediction has not been formally assessed, so the guidelines do not recommend integrating it into formal CVD risk assessment. Frailty may however,
216. Guidelines: 2021 ESC Cardiovascular Prevention – Question #13 with Dr. Eugene Yang
Jun 30, 2022
The following question refers to Section 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Mayo Clinic Fellow Dr. Teodora Donisan, and then by expert faculty Dr. Eugene Yang.
Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #13
You are seeing a 45-year-old woman with a past medical history of hypertension, overweight status, hyperlipidemia, and active tobacco use disorder. Her BMI is 27 kg/m2, BP is 150/75, HbA1C is 5.8%, total cholesterol is 234 mg/dL, HDL is 59 mg/dL, and LDL is 155 mg/dL. She is from Romania, a country with very high CVD risk. Which of the following statements is CORRECT?
A. LDL-C needs to be decreased by at least 50%, as small absolute LDL-C reductions would not provide clinical benefit
B. Hypertension is not an important CVD risk factor in our patient, as she is young.
C. Prediabetes is not a significant CV risk factor for our patient, as she is not yet diabetic.
D. Smoking confers a higher CVD risk for women than for men.
E. Her weight does not increase her CVD risk, as she is overweight rather than obese
Answer #13
The correct answer is D – Smoking confers a higher CVD risk for women than for men.
Prolonged smoking increases the CVD risk more in women than in men. Our patient is 45 years old. CVD risk in smokers < 50 years-old is 5x higher than in non-smokers. Of note, smoking is responsible for 50% of all avoidable deaths in smokers and a lifetime smoker will lose 10 years of life, on average. Secondhand smoke and smokeless tobacco can also increase the CVD risk.
Option A is incorrect. The SCORE2 risk chart for populations at very high CVD risk places her at a 14% (very high) 10-year risk for myocardial infarction, stroke, or cardiovascular death. She would derive benefit even from incremental reductions in LDL-C values. The absolute benefit of lowering LDL-C depends on both the absolute risk of ASCVD and the absolute reduction in LDL-C, so even a small absolute reduction in LDL-C may be beneficial in high- or very-high-risk patients. Furthermore, the reduction in CVD risk is proportional to the decrease in LDL-C, irrespective of the medications used to achieve such change. This remains true even when lowering LDL-C values to < 55 mg/dl.
Option B is incorrect. Hypertension is a major cause of CVD regardless of age, and the risk of death from either CAD or stroke increases linearly from BP levels as low as 90 mmHg systolic and 75 mmHg diastolic upwards. Particularly relevant for our patient, lifetime BP evolution differs in women compared to men, potentially resulting in an increased CVD risk at lower BP thresholds.
Option C is incorrect. Type 1 DM, type 2 DM, and prediabetes are all independent risk factors for ASCVD. Of note, it would be important to address this risk factor with our patient, as women who develop type 2 diabetes have a particularly high risk for stroke.
Option E is incorrect. All-cause mortality is lowest at a BMI on 20-25 kg/m2 in apparently healthy patients. Even overweight patients are at increased CVD risk. There is a linear relationship between BMI and mortality in non-smokers and a J-shaped relationship in ever-smokers. In patients with heart failure, a lower mortality risk has been observed with higher BMI – the “obesity paradox.” It would be important to evaluate the waist circumference in our patient, as both BMI and waist circumference are associated with ASCVD risk.
215. Atrial Fibrillation: Screening, Detection, and Diagnosis of Atrial Fibrillation with Dr. Ben Freedman
Jun 27, 2022
CardioNerds (Dr. Kelly Arps, Dr. Colin Blumenthal, Dr. Dan Ambinder, and Dr. Teodora Donisan) discuss the screening, detection, and diagnosis of atrial fibrillation (AF) with Dr. Ben Freedman. AF is frequently undiagnosed and its first manifestation can be a debilitating stroke. European and American guidelines differ slightly with regards to guidelines for AF screening in asymptomatic individuals. There are multiple methods available to screen for AF; the setting and the clinical scenario can help guide the choice. Consumer-led screening has its own challenges, as it can detect AF in a younger population where we should prioritize aggressive management of risk factors and comorbidities. There is uncertainty regarding the minimum AF burden that increases thromboembolic risk, however a high CHAD2S2-VASc score remains the strongest predictor of stroke risk independent of AF burden. Perioperative AF associated with non-cardiac surgery has increased risk of future stroke and adverse cardiac outcomes and should likely be treated as a new diagnosis of chronic AF.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This series is supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
We have collaborated with VCU Health to provide CME. Claim free CME here!
Disclosures: Dr. Ben Freedman disclosed that he has received grant or research support from Pfizer.
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Pearls and Quotes - Screening, Detection, and Diagnosis of Atrial Fibrillation
“Stroke is a poor early sign of AF.” AF remains frequently undiagnosed and there remains uncertainty about the optimal target population and screening methodology. “We have to tailor AF screening to the purpose we’re using it for” If in a primary care setting, check the pulse. If the goal is to exclude high-risk AF – handheld ECG for heart rhythm snapshots are appropriate. If the goal is to identify or exclude AF with a high level of certainty, continuous monitors are necessary for greater sensitivity. Consumer-led screening is performed by (mostly young) individuals using commercial monitors and smart watches, facilitating earlier recognition of paroxysmal AF in this population. In these cases, we should prioritize aggressive management of risk factors and comorbidities to reduce the risk of progression to persistent AF. There is no specific cutoff for AF duration which has been identified to predict elevated stroke risk; AF is likely both a risk factor and a risk marker for stroke, suggesting an underlying atrial myopathy. Non-cardiac surgeries and procedures can be considered “AF stress tests.” If AF occurs in these settings, it is usually more clinically significant and has a higher risk of stroke and death than AF associated with cardiac surgeries.
Notes - Screening, Detection, and Diagnosis of Atrial Fibrillation
Notes drafted by Dr. Teodora Donisan and reviewed by Dr. Kelly Arps
1. Why is it important to screen for AF and who should be screened?
AF is frequently undiagnosed and its first manifestation can be a debilitating stroke or death. Let’s go over a few numbers:
15% of people with AF are currently undiagnosed and 75% of those individuals would be eligible for anticoagulation.1 10-38% of individuals with ischemic strokes are found to have AF as a plausible cause, and the true proportion may be even higher,
214. Lipids: Review of Icosapent Ethyl with Dr. Michael Shapiro
Jun 19, 2022
CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic), Rick Ferraro (cardiology fellow at the Johns Hopkins Hospital), and Dr. Xiaoming Jia (Cardiology Fellow at Baylor College Medicine) take a closer look at the mechanism of icosapent ethyl in triglyceride lowering and ASCVD risk reduction with Dr. Michael Shapiro, the Fred M. Parrish professor of cardiology at Wake Forest University and Director of the Center for Preventative Cardiology at Wake Forest Baptist Health. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Relevant disclosures: None
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Pearls - Icosapent Ethyl
Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are two major Omega-3 fatty acids found in fish oil. While both have been shown to lower triglycerides, only purified EPA formulations have been shown to reduce ASCVD risk.Mechanisms of triglyceride (TG) lowering by icosapent ethyl are multiple and include reduction of hepatic VLDL production, stimulation of lipoprotein lipase activity, increased chylomicron clearance, reduced lipogenesis, increased beta oxidation, and reduced delivery of fatty acids to the liver.There was only modest reduction of triglycerides in REDUCE-IT and JELIS despite association with significant reduction in cardiovascular outcome events, suggesting likely mechanisms outside of triglyceride lowering that may contribute to ASCVD reduction.While there was an increased signal for peripheral edema and atrial fibrillation associated with icosapent ethyl in prior trials, overall side effect rates were very low.Icosapent ethyl is considered to be cost-effective based on cost-effective analysis.
Show notes - Icosapent Ethyl
EPA and DHA have differing biological properties that may explain differences in ASCVD risk reduction observed in cardiovascular outcome trials 1.The REDUCE-IT trial, which enrolled secondary prevention and high-risk primary prevention patients with elevated triglycerides who were on statin therapy, showed significant reduction of major adverse cardiovascular events in the icosapent ethyl group compared with a mineral oil placebo2. Only modest reductions of TG were seen in the REDUCE-IT and JELIS trials despite association with significant reduction in events 2,3. Potential mechanisms contributing favorable effects of EPA on ASCVD risk reduction include inhibition of cholesterol crystal formation, stabilization of membrane structures, reversal of endothelial dysfunction, inhibition of lipoprotein and membrane lipid oxidation 4.Pleotropic effects of EPA include influence on platelet aggregation, lower thromboxane activity, increased prostaglandin level, and effects on blood pressure, insulin resistance and inflammation.Triglycerides are a surrogate for triglycerides-rich lipoproteins, which are likely causally associated with ASCVD 5.There is increased signal for bleeding, lower extremity edema, and atrial fibrillation with icosapent ethyl but overall side effect rates are very low 2.In order to ensure higher rates of medication access and adherence, clinicians must be cognizant of the cost to the patient. In practice, it is important to have a structured approach to improve insurance approval rate for medications that require prior authorizationsWith icosapent ethyl, cost effectiveness analyses have shown the medication is cost-effect for ASCVD risk reduction in secondary...
213. ACHD: Transitions of Care in Congenital Heart Disease with Dr. Peter Ermis and Dr. Scott Cohen
Jun 15, 2022
CardioNerd (Amit Goyal), ACHD series co-chair Dr. Agnes Koczo (UPMC), and episode FIT lead, Dr. Logan Eberly (Emory University, incoming ACHD fellow at Boston Adult Congenital Heart) join Dr. Peter Ermis (Program Director of the Adult Congenital Heart Disease Program at Texas Children's Heart Center), and Dr. Scott Cohen (Associate Professor and Director of the Adult Congenital Heart Disease Program at the Medical College of Wisconsin) for a discussion about transitions of care in congenital heart disease. Audio editing by Dr. Gurleen Kaur (Director of the CardioNerds Internship and CardioNerds Academy Fellow).
Congenital heart disease (CHD) is the most common clinically significant congenital defect, occurring in approximately 1 in 100 live births. With modern advances in pediatric cardiology and cardiac surgery, over 90% of children born in the developed world with CHD will now survive into adulthood, and there are currently more adults than children living with CHD in the United States1.
As these children become adults, they will need to transition their care from pediatric to adult-centered care. Unfortunately, during this transition period, there is often delayed or inappropriate care, improper timing of the transfer of care, and undue emotional and financial stress on the patients, their families, and the healthcare system. At its worst, patients are lost to appropriate follow-up. In this episode, we review the current climate in transitions of care for CHD patients from child-centered to adult-centered care, discuss the difficulties that can occur during the transitions process. We further discuss how to mitigate them, and highlight the key elements to the successful transitions of care.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
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Pearls - Transitions of Care in Congenital Heart Disease
There is a clear distinction between the TRANSFER of care and TRANSITION of care. Transfer is merely moving from a pediatric to adult provider. Transition involves the continuing education of the patient with regards to their congenital heart disease, the importance of longitudinal follow up, and leading patients toward more autonomous medical care. Transition begins in the pediatric cardiology clinic prior to the transfer of care and is an ongoing process that continues well after the physical transfer of care.
A critical aspect of the transition and transfer of care is cultivating trust—that is, the new adult congenital heart disease (ACHD) provider must earn the trust of the patient and family. A failure to do so will inevitably prevent an optimal transition of care.
During transition, parents are transitioning along with their children. With transition to adult care, there is also a goal to transition responsibility for medical care from the parent to the child. Setting goals and expectations can help both the parents and the child effectively make this transition.
Loss to follow up is one of the most concerning complications ...
212. Narratives in Cardiology: Becoming & Thriving as a Fellowship Program Director with Dr. Katie Berlacher and Dr. Julie Damp – Tennessee Chapter
Jun 03, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), join Dr. Gurleen Kaur (Director of CardioNerds Internship and medicine resident at Brigham and Women’s Hospital), Dr. Victoria Thomas (Cardionerds Ambassador, Vanderbilt University Medical Center) Dr. Katie Berlacher (Cardiology program director, University of Pittsburgh Medical Center), and Dr. Julie Damp (Vanderbilt University Medical Center Cardiovascular disease fellowship program director) to discuss becoming & thriving as a fellowship program director and more in this installment of the Narratives in Cardiology Series. Special message by Tennessee ACC State Chapter Governor, Dr. John L Jefferies. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • Production Team
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Tweetorial - Becoming & Thriving as a Fellowship Program Director with Dr. Katie Berlacher and Dr. Julie Damp
https://twitter.com/gurleen_kaur96/status/1542620967733805056?s=21&t=AMSKElEz4oZZTA9nVbWBCA
Video version - Becoming & Thriving as a Fellowship Program Director with Dr. Katie Berlacher and Dr. Julie Damp
https://youtu.be/E-C-SSV7LZg
Notes - Becoming & Thriving as a Fellowship Program Director with Dr. Katie Berlacher and Dr. Julie Damp
Drafted by Dr. Victoria Thomas.
1. What does it mean to be a big “E” when people say they are a clinician Educator?
It can mean teaching students directly at bedside. However, it is also a sacrifice of daily mentoring and listening to students’ challenges and difficulties.Being a clinician educator is just as much of a calling as is serving in medicine.Clinician Educators focus on medicine but also the science and best practices of teaching the art of doctoring.
2. What is physician burnout? Why is this important for to CardioNerds?
Physician burnout is a syndrome of chronic workplace stress that leads to emotional exhaustion and a sense of dissatisfaction and disconnection personally and professionally. 30-45% of cardiologists have reported physician burnout.
3. What factors affect physician burnout?
Emotional and physical exhaustion often lead to physician burnout. First year of training as an intern or fellow and first year of serving as an attending are particularly high-risk periods. This is largely due to learning a new system and responsibilities mixed with a sense of decreased accomplishment.The sense of decreased accomplishment can lead to physicians suffering from impostor syndrome.Grit can be defined as a perseverance for long-term goals. The level of grit was not associated with burnout among first-year Internal Medicine residents.
4. What are some of the solutions to prevent or address physician burnout?
Physicians need to feel a sense of belonging and should be supported and celebrated when they have accomplished something by their colleagues and administrators. Fellows and attendings want to feel listened to and supported.Destigmatizing this idea of “perfection in medicine”.
211. Case Report: A Zebra in Polka Dots – Coronary Intervention With Glanzmann Thrombasthenia – UCLA
May 29, 2022
CardioNerds (Amit and Dan) join Dr. Omid Amidi (CardioNerds Academy Graduate) and Dr. Marwah Shahid from the UCLA Cardiology Fellowship program along with Dr. Evelyn Song (CardioNerds Academy House Faculty and Heart Failure Hospitalist at UCSF) to discuss a complex case focused on management of severe coronary artery disease in a patient with Glanzmann thrombasthenia. Dr. Rushi Parikh (Interventional cardiologist, UCLA) provides the ECPR for this episode. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
Glanzmann Thrombasthenia is a bleeding disorder due to impairment of platelet aggregation secondary to a mutation in the GPIIB/IIIA receptor. This case is focused on work up of stable coronary artery disease followed by a discussion on duration of dual antiplatelet therapy post percutaneous coronary intervention in a patient with Glanzmann thrombasthenia.
Check out this published case in JACC: Case Reports
Jump to: Case media - Case teaching - References
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Case Media
See the published case in JACC: Case Reports
Episode Schematics & Teaching
Pearls
1. Patients with Glanzmann thrombocytopenia (GT) may have a higher risk of bleeding, depending on their disease phenotype.
2. It is unclear whether the mechanism of GT protects patient against stent thrombosis in the setting of PCI. Additionally, there is little data on the use of antiplatelet agents in patients with GT.
3. Short-term DAPT may be a reasonably safe option for patients with GT undergoing PCI.
4. We report a successful case of percutaneous coronary intervention in a patient with GT with no complications at a 1 year follow up.
Notes
1. What is Glanzmann thrombasthenia?
GT is an inherited platelet disorder that is characterized by spontaneous bleeding with phenotypic variability ranging from minimal bruising to potentially fatal hemorrhaging. GT is caused by autosomal recessive inheritance of quantitative or qualitative deficiencies of functional αIIbβ3 integrin coded by ITGA2B or ITGB3 genes for αIIb and β3, respectively. As a result, platelets may be stimulated, but the platelet glycoprotein IIb/IIIa receptor is unable to bind fibrinogen to cross-link platelets, rending them potentially ineffective. In platelet aggregation studies, there is lack of response to collagen, epinephrine, arachidonic acid, and ADP stimulation. Thus, platelet aggregation is impaired.
2. What is known about PCI and antiplatelet therapy in the setting of Glanzmann thrombasthenia?
To the best of our knowledge, this is the first case report of percutaneous coronary intervention in the setting of GT. It is unclear if the mechanism of GT alone provides sufficient antiplatelet activity and whether antiplatelet therapy leads to significantly increased bleeding risk. The use of antiplatelet therapy is not well studied in the GT population. What we do know is that the mechanism of GT prevents platelet aggregation—the final step in platelet-related thrombosis—while oral antiplatelet therapy affects platelet activation, thus, in our patient we felt that short term DAPT was reasonable. It is important to note that in the event of an active bleed requiring platelet transfusion, donor platelets possess functional glycoprotein IIb/IIIa receptors and thus exponentially increase the risk of stent thrombosis. Therefore, unlike our case, if a patient is not maintained on chronic oral antiplatelet therapy, initiation of oral or intravenous antiplatelet therapy should be considered to prevent stent thrombosis at the time of platelet transfusion.
Like any other patient with a high bleeding risk, it is important to have clear indications to conduct a coronary angiogram in patient...
210. Family History of Premature ASCVD with Dr. Ann Marie Navar
May 27, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Ahmed Ghoneem (CardioNerds Academy Chief of House Taussig and medicine resident at Lahey Hospital), and Dr. Gurleen Kaur (Director of CardioNerds Internship and medicine resident at Brigham and Women’s Hospital) discuss family history of premature ASCVD with Dr. Ann Marie Navar, Preventive Cardiologist and Associate Professor in the Departments of Internal Medicine and Population and Data Sciences at UT Southwestern Medical Center. They discuss the art of soliciting a nuanced family history, refining cardiovascular risk using risk models and novel markers, counseling patients with elevated risk, and more. Show notes were drafted by Dr. Ahmed Ghoneem and reviewed by Dr. Gurleen Kaur. Audio editing was performed by CardioNerds Intern, student Dr. Adriana Mares.
For related teaching, check out this Tweetorial about CAC by Dr. Gurleen Kaur, the Family History of Premature ASCVD Infographic by Dr. Ahmed Ghoneem, and the CardioNerds Cardiovascular Prevention Series.
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Show notes - Family History of Premature ASCVD with Dr. Ann Marie Navar
Patient summary: Mr. B is a 51-year-old gentleman who is referred to CardioNerds Prevention Clinic by his PCP. He does not have a significant past medical history. He is a former smoker but quit 2 years ago. His BP in clinic today is 138/84; he is not on any antihypertensives. His most recent lipid profile 2 weeks prior showed a total cholesterol level of 250 mg/dL, a TG level of 230 mg/dL, an LDL cholesterol of 174 mg/dL, and an HDL cholesterol of 30 mg/dL. He tells us that his father had a “heart attack” at the age of 52, and he would like to further understand his own risk. We calculate his ASCVD risk score, and it is 9.8%.
1. What constitutes a positive family history (FHx) of premature ASCVD? What is an approach to the art of soliciting the FHx from our patients?
Definition of family history of premature ASCVD: the history of an atherosclerotic event (e.g., myocardial infarction or stroke) in a male first degree relative before the age of 55 or a female first degree relative before the age of 65.
Dr. Navar’s approach to soliciting a family history:Lead with a general question such as “what do you know about any medical conditions that run in your family?”.Then ask more specific questions about the parents and siblings, such as “Is your mother still alive? How long did she live? Has she ever had a heart attack or stroke?”If the answer is yes, ask about how old they were at the time of the event.A challenging aspect of the FHx can be eliciting the difference between atherosclerotic events and sudden cardiac death. While atherosclerotic diseases are a much more common cause of unexplained sudden death, it's important that we don't miss the opportunity to identify inherited cardiomyopathies, channelopathies, inherited aortopathies or other heritable SCD syndromes.
2. Is the “dose” of family history important (for example: the number of affected relatives, the closeness of those relationships, the age of onset)?
While conducting studies to test this may be difficult, the few studies that have looked at the number of affected relatives have found a dose-response type relationship, where increasing number of relatives affected increases the risk of heart disease.1,2
3. How does a family history affect cardiovascular risk stratification?
FHx of premature ASCVD does not improve the predictive ability of the Pooled Cohort Equations (PCE) at a population level. Therefore, it does not factor into the ASCVD risk calculation utilizing the PCE.
However, it enhances the patient’s risk at an individual level. The ACC/AHA guidelines recognize FHx of premature ASCVD as a risk-enhancing factor [together with CKD, chronic inflammatory conditions such as psoriasis, primary hypercholesterolemia, high-risk ethnicity such as South Asian ancestry...
209. CardioNerds Rounds: Challenging Cases – Modern Guideline Directed Therapy in Heart Failure with Dr. Randall Starling
May 24, 2022
It’s another session of CardioNerds Rounds! In these rounds, Co-Chairs, Dr. Karan Desai and Dr. Natalie Stokes and Dr. Tiffany Dong (FIT at Cleveland Clinic) joins Dr. Randall Starling (Professor of Medicine and Director of Heart Transplant and Mechanical Circulatory Support at Cleveland Clinic) to discuss the nuances of guideline directed medical therapy (GDMT) through real cases. As a past president of the Heart Failure Society of America (HFSA) and author on several guidelines, Dr. Starling gives us man pearls on GDMT. Come round with us today by listening to the episodes and joining future sessions of #CardsRounds!
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Cases discussed and Show Notes • References • Production Team
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Show notes - CardioNerds Rounds: Challenging Cases - Modern Guideline Directed Therapy in Heart Failure with Dr. Randall Starling
Case #1 Synopsis:
A man in his 60s with known genetic MYPBC3 cardiomyopathy and heart failure with a reduced ejection fraction of 30% presents with worsening dyspnea on exertion over the past 6 months. His past medical history also included atrial fibrillation with prior ablation and sick sinus syndrome with pacemaker implantation. Medications are listed below. He underwent an elective right heart catheterization prior to defibrillator upgrade for primary prevention. At the time of right heart catheterization, his blood pressure was 153/99 with a heart rate of 60. His RHC demonstrated a RA pressure of 15mmHg, RV 52/16, PA 59/32 (mean 41), and PCWP 28 with Fick CO/CI of 2.8 L/min and index of 1.2 L/min/m2. His SVR was 1900 dynes/s/cm-5. He was admitted to the cardiac ICU and started on nitroprusside that was transitioned to a regimen of Sacubitril-Valsartan and Eplerenone. His final RHC numbers were RA 7, PA 46/18/29, PCWP 16 and Fick CO/CI 6.1/2.6. His discharge medications are shown below.
Takeaways from Case #1
Unless there are contraindications (cardiogenic shock or AV block), continue a patient’s home beta blocker to maintain the neurohormonal blockade benefits. A low cardiac index should be interpreted in the full context of the patient, including their symptoms, other markers of perfusion (e.g., urine output, mentation, serum lactate), and mean arterial pressure before holding or stopping beta blockade. Carvedilol, metoprolol succinate and bisoprolol are all evidence-based options for beta blockers in heart failure with reduced ejection fraction.If there is concern of lowering blood pressure too much with Sacubitril/Valsartan, one method is to trial low dose of valsartan first and then transition to Sac/Val. Note, in the PARADIGM-HF trial, the initial exclusion criteria for starting Sac/Val included no symptomatic hypotension and SBP ≥ 100. At subsequent up-titration visits, the blood pressure criteria was decreased to SBP ≥ 95.In multiple studies, protocol-driven titration of GDMT has shown to improve clinical outcomes, yet titration remains poor. The following image from Greene et al. in JACC shows that in contemporary US outpatient practices that GDMT titration is poor with few patients reaching target dosing.
Case #2 Synopsis:
A 43 year-old male with a past medical history of familial dilated cardiomyopathy requiring HVAD placement two years prior now comes in with low flow alarms.
208. Atrial Fibrillation: Epidemiology, Health Equity, & The Double Paradox with Dr. Larry Jackson
May 20, 2022
Atrial fibrillation may reach pandemic proportions in the next 2-3 decades. Factors that drive this phenomenon have been studied in predominantly White populations, leading to a significant underrepresentation of certain racial/ethnic groups in atrial fibrillation epidemiological studies. Most atrial fibrillation epidemiology studies suggest that the non-Hispanic Black population has a lower incidence/prevalence of atrial fibrillation, despite a higher risk factor burden (“Afib paradox”). At the same time, non-Hispanic Blacks have worse outcomes compared to the White population and underrepresented populations and women are less likely than White men to receive optimal guideline-based therapies for atrial fibrillation.
In this episode, CardioNerds Dr. Kelly Arps (Co-Chair Atrial Fibrillation series, Cardiology fellow at Duke University), Dr. Colin Blumenthal (Co-Chair Atrial Fibrillation series, CardioNerds Academy House Faculty Leader for House Jones, Cardiology fellow at the University of Pennsylvania), and Dr. Dinu-Valentin Balanescu (CardioNerds Academy Faculty for House Jones, rising internal medicine chief resident at Beaumont Hospital), discuss with Dr. Larry Jackson (cardiac electrophysiologist and Vice Chief of Diversity, Equity, and Inclusion in the Division of Cardiology at Duke University) about atrial fibrillation epidemiology and health equity, challenges and possible solutions to improving diversity in clinical trials, and race/ethnicity/sex/gender differences in the detection, management, and outcomes of atrial fibrillation. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.
This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal.
This series is supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds.
We have collaborated with VCU Health to provide CME. Claim free CME here!
Disclosure: Larry R. Jackson II, MD, MHs, has the following relevant financial relationships:Advisor or consultant for: Biosense Webster Inc.Speaker or a member of a speakers bureau for: Biotronik Inc.; Medtronic Inc.
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls and Quotes - Atrial Fibrillation: Epidemiology, Health Equity, & The Double Paradox
Atrial fibrillation confers an enormous public health burden. It is estimated that it will reach pandemic proportions over the next 30 years, with potentially 100-180 million people worldwide suffering from this condition.Large epidemiological atrial fibrillation registries have very small populations of underrepresented groups. More diverse enrollment in clinical trials is essential and may be obtained by increasing diversity among research staff, principal investigators, and steering committees, and use of mobile/telehealth technologies to remove bias related to differences in presentation. The CardioNerds Clinical Trials Network specifically aims pair equitable trial enrollment with trainee personal and professional development.Most atrial fibrillation epidemiology studies suggest that the non-Hispanic Black population has lower incidence/prevalence of atrial fibrillation, despite higher risk factor burden. This “paradox” is likely due to a multifactorial process, with clinical differences, socioeconomic factors, and genetic factors contributing.Underrepresented populations are less likely than White patients to receive optimal guideline-based management of atrial fibrillation.
207. Lipids: REDUCE-IT Versus STRENGTH Trials – EPA in Clinical Practice with Dr. Peter Toth
May 16, 2022
CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic), Rick Ferraro (cardiology fellow at the Johns Hopkins Hospital), and Dr. Aliza Hussain (cardiology fellow at Baylor College Medicine) take a deep dive on the REDUCE-IT trial with Dr. Peter Toth, director of preventive cardiology at the CGH medical center in Sterling, Illinois, clinical professor in family and community medicine at the University of Illinois School of Medicine, and past president of the National Lipid Association and the American Board of Clinical Lipidology. Special introduction to CardioNerds Clinical Trialist Dr. Jeff Wang (Emory University). Audio editing by CardioNerds academy intern, Shivani Reddy.
This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Relevant disclosures: None
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Pearls - REDUCE-IT
The Reduction of Cardiovascular Events with EPA-Intervention Trial (REDUCE-IT) trial was a large randomized controlled trial that showed a significant reduction in atherosclerotic cardiovascular disease (ASCVD) events with use of icosapent ethyl ester in secondary prevention patients and high risk primary prevention patients with diabetes and residual elevated triglycerides between 135 to 499 mg/dL on top of maximally tolerated statin therapy1.
Despite the use of high intensity statin therapy, considerable residual risk for future atherosclerotic cardiovascular disease exists in patients with ASCVD.Elevated triglycerides (TGs) are an important marker of increased residual ASCVD risk2.There are two primary types of Omega-3 fish oils: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Omege-3 fish oils have been shown to lower triglyceride levels.Low-dose combination EPA and DHA has not exhibited incremental cardiovascular benefit in either primary prevention and secondary prevention patients on top of statin therapy3-5.REDUCE-IT showed the use of high dose EPA in patients with either ASCVD or DM and one additional risk factor, and relatively well-controlled LDL-C levels on maximally tolerated statin therapy and residual hypertriglyceridemia (TG 135-499 mg/dL) results in significant reductions in cardiovascular events over a median follow-up period of 4.9 years1.
Show notes - REDUCE-IT
Multiple epidemiologic and Mendelian randomization studies have established elevated triglyceride (TG) levels as an important risk factor for atherosclerotic cardiovascular events6-8. However previous clinical trials using TG-lowering medication such as niacin, fibrates and low dose omega-3 fish oil have not shown to reduce cardiovascular events when added to statin therapy in patients with or without ASCVD,9,10.The JELIS trial first demonstrated a significant reduction in cardiovascular events when 1.8g daily of eicosapentaenoic acid (EPA) was added to low-intensity statin therapy in patients with ASCVD and hypercholesterolemia, However, the trial was limited due to open label design without placebo, use of low doses of background statin therapy, and geographic/demographic limitations to participants in Japan11.In a large international multicenter randomized controlled trial, the Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) randomized 8,179 patients with established atherosclerotic heart disease or diabetes and an additional risk factor, on maximally tolerated statin therapy, to 4 gm/day of icosapent ethyl (a highly purified and stable EPA ethyl ester) or miner...
206. Guidelines: 2021 ESC Cardiovascular Prevention – Question #12 with Dr. Laurence Sperling
May 13, 2022
The following question refers to Section 4.11 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSF resident Dr. Jessie Holtzman, and then by expert faculty Dr. Laurence Sperling.
Dr. Laurence Sperling is the Katz Professor in Preventive Cardiology at the Emory University School of Medicine and Founder of Preventive Cardiology at the Emory Clinic. Dr. Sperling was a member of the writing group for the 2018 Cholesterol Guidelines, serves as Co-Chair for the ACC's Cardiometabolic and Diabetes working group, and is Co-Chair of the WHF Roadmap for Cardiovascular Prevention in Diabetes.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #12
Medically supervised cardiac rehabilitation programs after ASCVD events and for patient with heart failure carries a Class I recommendation. However, placement of referrals, uptake and enrollment after referral, and rigor of rehabilitation all remain inconsistent. What minimum cumulative duration of cardiac rehabilitation has been chosen as a threshold of effectiveness for cardiac rehabilitation by the European Society of Cardiology?
A. 100-300 minutes, 10 sessions
B. 300-500 minutes, 16 sessions
C. 500-700 minutes, 22 sessions
D. 700-1000 minutes, 28 sessions
E. >1000 minutes, 36 sessions
Answer #12
The correct answer is E: >1000 minutes across 36 sessions.
Cardiac rehabilitation is a comprehensive, multidisciplinary intervention not just including exercise training and physical activity counselling, but also education, risk factor modification, diet/nutritional counselling, and vocational and psychosocial support.
A broad evidence base demonstrates that multidisciplinary cardiac rehabilitation and prevention programs after ASCVD events or revascularization reduce recurrent cardiovascular hospitalizations, myocardial infarction, and cardiovascular mortality. In patients with chronic HF (mainly HFrEF), exercise based cardiac rehabilitation (EBCR) may improve all-cause mortality, reduce hospital admissions, and improve exercise capacity and quality of life. Such programs include a wide array of activities including physical activity, risk factor modification, psychosocial support, nutrition counseling, and more. Despite the heterogenous design of clinical trials, cardiac rehabilitation has been shown to be a cost-effective intervention.
Based upon the available review data, the European Association of Preventive Cardiology and the European Society of Cardiology proposed minimum standards for secondary prevention cardiac rehabilitation programs. Based upon a comprehensive review of the literature, ESC recommends that cardiac rehabilitation be multidisciplinary, supervised by health professionals, and start as soon as possible after a cardiovascular event. Cardiac rehabilitation should include both aerobic and muscular resistance tailored to the fitness level of the participant, should carry a duration of >1000 minutes in total, and should exceed 36 sessions total.
While uptake remains limited, electronic prompts within the medical record and automatic referrals should be considered to enhance referral and participation. Future research should continue to explore the benefit of home-based cardiac rehabilitation with or without telemonitoring. Lastly, studies have shown that uptake remains lower among women, and targeted programs should be undertaken to address such disparities.
Main Takeaway
Current European Society of Cardiology guidelines provide a Class I (LOE A) recommendation for the participation in multidisciplinary cardiac rehabilitation programs for the secondary prevention of ASCVD events including revascularization and in individuals with heart failure (mainly HFrEF) to improve patient outcomes.
205. Guidelines: 2021 ESC Cardiovascular Prevention – Question #11 with Dr. Eugenia Gianos
May 12, 2022
The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD cardiology fellow Dr. Harpreet Bhatia, and then by expert faculty Dr. Eugenia Gianos.
Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the director of the Women’s Heart Program at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #11
A 70-year-old man with a history of hypertension, diabetes, hyperlipidemia, peptic ulcer disease with a prior upper GI bleed, as well as coronary artery disease presents to clinic. About one year ago he suffered an NSTEMI treated with percutaneous coronary intervention to the mid LAD. He is feeling well and able to walk 1 mile daily with no anginal symptoms. He is currently taking aspirin 81 mg daily, ticagrelor 90 mg BID, atorvastatin 40 mg daily, metoprolol 25 mg BID, lisinopril 5 mg daily, and lansoprazole 15mg daily. He has a preserved ejection fraction. His BP in clinic is 110/70 and HR is 65 bpm. His LDL is 50 mg/dL. What do you recommend for his further management?
A. Switch ticagrelor to clopidogrel, continue indefinitelyB. Stop ticagrelor, continue aspirin indefinitelyC. Continue aspirin + ticagrelor indefinitelyD. Stop ticagrelor, start rivaroxaban 2.5 mg BIDListen to the podcast episode!
Answer #11
The correct answer is B – stop ticagrelor, continue aspirin indefinitely.Twelve months of DAPT is recommended for acute coronary syndromes (Class I, LOE A). Long-term secondary prevention with dual anti-thrombotic therapy (DAPT > 12 months with a P2Y12 inhibitor and low-dose aspirin or low-dose rivaroxaban 2.5mg BID with low-dose aspirin) may be considered for patients who are at high ischemic risk without high risk of bleeding (Class IIa, LOE A). However, this patient is at increased bleeding risk (peptic ulcer disease with prior GI bleeding) and has no ischemic symptoms, and so neither would be recommended.Main TakeawayIn summary, 12 months of DAPT is recommended after ACS. Prolonged DAPT or low-dose rivaroxaban may be considered with high ischemic risk and low bleeding risk.Guideline LocationSection 6.1, Pages 3294-3295.
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204. Guidelines: 2021 ESC Cardiovascular Prevention – Question #10 with Dr. Eileen Handberg
May 11, 2022
The following question refers to Section 4.6 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Shivani Reddy, answered first by NP Carol Patrick, and then by expert faculty Dr. Eileen Handberg.
Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President Elect for the PCNA.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #10
Ms. DW is a 67-year-old woman with a history of coronary artery disease and prior percutaneous coronary intervention in 2019 with a drug-eluting stent to the proximal left anterior descending artery. They have transitioned to your clinic from a previous provider, and their LDL is 134 mg/dL. What would be the ESC recommended goal LDL-C level for this patient?
A. <30 mg/dL
B. <55 mg/dL
C. <70 mg/dL
D. <100 mg/dL
Answer #10
The correct answer is B.
The ESC guidelines outline a robust LDL-C reduction goal of <55mg/dL (<1.4mmol/L) and ≥50% reduction from baseline in those with known atherosclerotic cardiovascular disease, with the highest possible Class I (LOE A) recommendation for this goal. A goal LDL-C <55mg/dL with ≥50% reduction from baseline should also be considered in apparently healthy persons <70 years of age who are at very high risk (Class IIa, LOE C).
To achieve these goals, the guidelines recommend a stepwise approach to treatment including dietary, lifestyle, and medical management. Recognizing that lower LDL-C is better, the guidelines recommend liberal intensification of treatment especially if using submaximal doses of generic or low-cost statins and side effects are not apparent. High-intensity statin is recommended to be prescribed to the highest tolerated dose to reach LDL-C goals set for each specific risk group (Class I, LOE A). If these goals are not achieved with the maximum tolerated dose of a statin, combination therapy with ezetimibe is recommended (Class I, LOE B).
Choice A is incorrect. An LDL-C <30mg/dL is a more significant reduction than that recommended by the guidelines, even for patients with known ASCVD. Notably, for patients with ASCVD who experience a second vascular event within 2 years while taking maximum tolerated statin-based therapy, an LDL-C goal of <1.0 mmol/L (40 mg/dL) may be considered.
Choice C is incorrect. The ESC prevention guidelines recommend considering a goal of <70mg/dL for patients in the primary prevention setting at high risk who are <70 years of age (Class IIa, LOE C). (Recall again that for those at very high risk the primary prevention recommendation is target LDL-C <55 mg/dL).
Choice D is incorrect. LDL-C <100mg/dL was a frequently cited goal in older iterations of various prevention and lipid guidelines. As the data has shifted to support lower LDL-C goals, this is not a noted goal within the 2021 ESC prevention guidelines for patients <70 years of age.
Main Takeaway
Lower is better when it comes to LDL-C
For those with known atherosclerotic cardiovascular disease, liberal intensification of lipid lowering treatment is recommended.
Guideline Location
Section 4.6.2.1, page 3276-3279, Figure 6 on page 3252, Figure 7 on page 3253
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203. Guidelines: 2021 ESC Cardiovascular Prevention – Question #9 with Dr. Noreen Nazir
May 10, 2022
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir.
Dr. Noreen Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #9
Mr. A is a 28-year-old man who works as an accountant in what he describes as a “desk job” setting. He shares that life got “a little off-track” for him in 2020 between the COVID-19 pandemic and a knee injury. His 2022 New Years’ resolution is to improve his overall cardiovascular and physical health. He has hypertension and a family history of premature ASCVD in his father, who died of a heart attack at age 50. Prior to his knee injury, he went to the gym 3 days a week for 1 hour at a time, split between running on the treadmill and weightlifting. He has not returned to the gym since his injury and has been largely sedentary, although he is trying to incorporate a 20-minute daily walk into his routine. Which of the following exercise-related recommendations is most appropriate?
A. A target of 75-150 minutes of vigorous-intensity or 150-300 minutes of moderate-intensity aerobic physical exercise weekly is recommended to reduce all-cause mortality, CV mortality, and morbidity.
B. Bouts of exercise less than 30 minutes are not associated with favorable health outcomes.
C. Exercise efforts should be focused on aerobic activity, since only this type of activity is associated with mortality and morbidity benefits.
D. Light-intensity aerobic activity like walking is expected to have limited health benefits for persons with predominantly sedentary behavior at baseline.
Answer #9
The correct answer is A.
There is an inverse relationship between moderate-to-vigorous physical activity and CV morbidity/mortality, all-cause mortality, and incidence of type 2 diabetes, with additional benefits accrued for exercise beyond the minimum suggested levels. The recommendation to “strive for at least 150-300 min/week of moderate-intensity, or 75-150 min/week of vigorous-intensity aerobic physical activity, or an equivalent combination thereof” is a Class 1 recommendation per the 2021 ESC guidelines, and a very similar recommendation (at least 75 minutes of vigorous-intensity or 150 minutes of moderate-intensity activity) is also Class 1 recommendation per 2019 ACC/AHA primary prevention guidelines. Both the ESC and ACC/AHA provide examples of activities grouped by absolute intensity (the amount of energy expended per minute of activity), but the ESC guidelines also offer suggestions for measuring the relative intensity of an activity (maximum/peak associated effort) in Table 7, which allows for a more individualized, customizable approach to setting activity goals. Importantly, individuals who are unable to meet minimum weekly activity recommendations should still be encouraged to stay as active as their abilities and health conditions allow to optimize cardiovascular and overall health.
Choice B is incorrect, as data suggests physical activity episodes of any duration, including <10 min, are associated with favorable outcomes like all-cause mortality benefit. The duration of a single exercise bout is less correlated with health benefits than the total physical activity time accumulated per week.
Choice C is incorrect. Per the ESC guidelines, it is a class 1 recommendation to perform resistance exercise, in addition to aerobic activity, on 2 or more days per week to reduce all-cause mortality. Data indicate that the addition of resistance exercise to aerobic activity is assoc...
202. Guidelines: 2021 ESC Cardiovascular Prevention – Question #8 with Dr. Eugene Yang
May 09, 2022
This question refers to Sections 3.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern, student Dr. Hirsh Elhence, answered first by internal medicine resident at Beaumont Hospital and soon to be Mayo Clinic cardiology fellow and Dr. Teodora Donisan and then by expert faculty Dr. Eugene Yang.Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #8
Please read the following patient vignettes and choose the FALSE statement.A. A 39-year-old man who comes for a regular physical, has normal vitals and weight, denies any significant past medical or family history – does not need systematic cardiovascular disease (CVD) assessment.B. A 39-year-old woman who comes for a regular physical, has normal vitals and weight, and has a history of radical hysterectomy (no other significant past medical or family history) – could benefit from systematic or opportunistic CVD assessment.C. A 39-year-old woman who comes for a regular physical, has normal vitals except for a BMI of 27 kg/m2 and a family history of hypertension – requires a systematic global CVD assessment.D. A 39-year-old man who comes for a regular physical, has normal vitals and weight, and has a personal history of type I diabetes – requires a systematic global CVD assessment.
Answer #8
The correct answer is C.Option A is an accurate statement, as systematic CVD risk assessment is not recommended in men < 40 years-old and women < 50 years-old, if they have no known cardiovascular (CV) risk factors. (Class III, level C)Option B is an accurate statement, as this patient had a radical hysterectomy, which means the ovaries have been removed as well and she is considered postmenopausal. Systematic or opportunistic CV risk assessment can be considered in men > 40 years-old and women > 50 years-old or postmenopausal, even in the absence of known ASCVD risk factors. (Class IIb, level C)Option C is a false statement and thus the correct answer, as the recommendations for global screening in this patient are not as strong and would require shared decision making. Opportunistic screening of blood pressure can be considered in her, as she is at risk for developing hypertension. Blood pressure screening should be considered in adults at risk for the development of hypertension, such as those who are overweight or with a known family history of hypertension. (Class IIa, level B)Option D is an accurate statement, as systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor (i.e., family history of premature CVD, familial hyperlipidemia, CVD risk factors such as smoking, arterial hypertension, DM, raised lipid level, obesity, or comorbidities increasing CVD risk). (Class I, level C)Additional learning points:Do you know the difference between opportunistic and systematic CVD screening?Opportunistic screening refers to screening without a predefined strategy when the patient presents for different reasons. This is an effective and recommended way to screen for ASCVD risk factors, although it is unclear if it leads to benefits in clinical outcomes.Systematic screening can be done following a clear strategy formally evaluating either the general population or targeted subpopulations (i.e., type 2 diabetics or patients with significant family history of CVD). Systematic screening results in improvements in risk factors but has no proven effect on CVD outcomes.
201. Guidelines: 2021 ESC Cardiovascular Prevention – Question #7 with Dr. Wesley Milks
May 08, 2022
The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks.
Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology's Cardiovascular Disease Prevention Leadership Council.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #7
While you are on holiday break visiting your family, your aunt pulls you aside during the family gathering to ask a few questions about your 70-year-old uncle. He has hypertension, hyperlipidemia, type 2 diabetes mellitus, and moderate chronic obstructive pulmonary disease. His medications include Fluticasone/Salmeterol, Tiotropium, Albuterol, Lisinopril, Simvastatin, and Metformin. She is very concerned about his risk for heart disease as he has never had his “heart checked out.” She asks if the presence of COPD increases his chance of having heart disease. Which of the following statements would best answer her question?
A. Systemic inflammation and oxidative stress caused by COPD promote vascular remodeling and a paradoxical ‘anticoagulant’ state affecting all vasculature types.
B. Although chronic COPD is associated with increased cardiovascular events, individual exacerbations have no impact on risk of cardiovascular events.
C. Patients with mild-moderate COPD are 8-10x more likely to die from atherosclerotic cardiovascular disease than respiratory failure.
D. Cardiovascular mortality increases proportionally with an increase in forced expiratory volume in 1 second (FEV1)
Answer #7
The correct answer is C.
Patients with mild-moderate COPD are 8-10x more likely to die from atherosclerotic cardiovascular disease than respiratory failure. Patients with COPD have a 2-3-fold increased risk of CV events compared to age-matched controls even when adjusted for tobacco smoking, a shared risk factor. This can be partly explained by other common risk factors including aging, hypertension, hyperlipidemia, and low physical activity.
Interestingly, CVD mortality increases proportionally with a decrease (rather than increase) in FEV1, making answer choice D wrong (28% increase CVD mortality for every 10% decrease in FEV1). Additionally, COPD exacerbations and related infections are associated with a 4x increase in CVD events, making answer choice B incorrect.
COPD has several effects on the vasculature which creates a ‘procoagulant’ not ‘anticoagulant’ effect on all vascular beds. This is associated with increased risk of cognitive impairment due to cerebral microvascular damage as well as increased risk of ischemic and hemorrhagic stroke.
Main Takeaway
The presence of COPD (even mild to moderate) has a significant impact on the incidence of non-fatal coronary events, stroke, and cardiovascular mortality mediated by inherent disease process and progression, risk factors (smoking, aging, hypertension, and hyperlipidemia), and systemic inflammation altering vasculature creating a ‘procoagulant’ effect. The ESC gives a Class I indication (LOE C) to investigate for ASCVD and ASCVD risk factors in patients with COPD.
Guideline Location
3.4.5, Page 3264.
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200. 2022 AHA/ACC/HFSA Guideline for The Management of Heart Failure – Hot Takes from The Journal of Cardiac Failure Family
May 06, 2022
CardioNerds (Amit Goyal, Daniel Ambinder) and special co-host Dr. Mark Belkin, join the Journal of Cardiac Failure Family to discuss the 2022 AHA/ACC/HFSA Guideline for The Management of Heart Failure. The JCF Editor-In-Chief Dr. Robert Mentz, Deputy Editor Dr. Anu Lala, and FIT editors -- Dr. Vanessa Bluemer, Dr. Ashish Corrhea, and Dr. Quinton Youmans -- share their hot takes and practical takeaways from the guidelines.
At JCF, we’re privileged to share this important document that will support improved care for those living with heart failure,” stated Editor-in Chief Dr. Robert J. Mentz and Deputy Editor Anu Lala. “The 2022 guidelines convey patient-centered updates regarding the language we use to communicate disease considerations (e.g., stages of HF) and practice-changing guidance around the diagnosis and management of HF including newer therapeutics (e.g., SGLT2i). There is an emphasis not only on managing HF but also on how to treat important comorbidities as part of the holistic care for patients living with HF."
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
Executive Summary
A Clinician's Guide to the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure by Dr. Michelle Kittleson
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Guideline Top 10 Take-Home Messages - Guideline for The Management of Heart Failure
1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i).
2. SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population.
3. New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARBs (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit).
4. Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment.
5.Value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published.
6. Amyloid heart disease has new recommendations for treatment including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.
7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%. Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement).
8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies, and uses palliative care including palliative inotropes where consistent with the patient's goals of care.
9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B.
10.Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders,
199. Case Report: The Perfect Storm of Complications Post-Partum – Summa Health
May 04, 2022
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Phoo Pwint Nandar (former FIT Ambassador), Dr. Deep Shah (current FIT Ambassador), and Dr. Sugat Wagle from the Summa Health Cardiology Department for an afternoon at Cuyahoga National Valley Park. We discuss a case of a post-partum woman who presented with ventricular fibrillation arrest due to SCAD. She had ongoing advanced cardiac life support (ACLS) for nearly 60 minutes before obtaining return of spontaneous circulation. We discuss the broad differential of VF arrest, including acute coronary syndrome and spontaneous coronary artery dissection (SCAD) – among many others. We also go over the etiology and management of SCAD as well the complications. Pregnancy is a crucial stressor to the cardiovascular system and understanding its hemodynamic changes is crucial to all physicians. The E-CPR segment is provided by Dr. Grace Ayafor, Interventional cardiology faculty, Summa Health.
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Case Media
Episode Schematics & Teaching - SCAD
Pearls - SCAD
SCAD remains underdiagnosed. It has a wide range of clinical presentations, including chest pain, ACS, VT/VF arrest, and cardiogenic shock.Underlying etiologies of SCAD include autoimmune diseases, connective tissue disorders, fibromuscular dysplasia, external stressors, and pregnancy.There are 3 types of SCAD, and coronary angiogram is the gold standard for diagnosis.Common areas of involvement of SCAD include left anterior descending and left circumflex arteries; however, SCAD can manifest in any coronary artery as well as simultaneously in multiple coronary arteries. Left main trunk involvement is rare, more likely to be associated with the peri-partum state, and requires complex management decisions guided by a heart team approach.Most SCAD cases are benign and treated conservatively, however, some require intervention (PCI or CABG) depending on clinical severity and course.Recurrent SCAD has been reported in 10-30% of the patients and aggressive management of hypertension is recommended.Guidelines regarding SCAD management are largely based on expert consensus due to a dearth of high-quality data. Efforts to raise awareness and study this syndrome are of paramount importance.
Notes - SCAD
1. What is SCAD and how does it present?
Spontaneous coronary artery dissection (SCAD) is defined as an epicardial coronary dissection that is not associated with atherosclerosis or instrumentation.This occurs with hematoma formation within the tunica media, thereby potentially compressing the arterial true lumen leading to ischemia.There are two proposed mechanisms of hematoma formation: “inside-out” and “outside-in”. The inside-out hypothesis posits that the hematoma arises from the true lumen via a dissection flap – an endothelial-intimal disruption. Conversely the outside-in hypothesis posits that the hematoma arises de novo within the media through disruption of traversing microvessels.There is a wide range of clinical presentation for SCAD varying in severity including asymptomatic / benign presentation, anginal syndromes, acute myocardial infarction, VT/VF arrest, and cardiogenic shock. Our patient presented with VF arrest and ACS.SCAD epidemiology is confounded by a lack of awareness. A high index of suspicion is warranted. Diagnosis can be missed in young or mid-life without CV risk factors who would present with atypical/mild chest pain.
2. What are the etiologies of SCAD?
SCAD is associated with the peripartum state (presumed due to combination of hormonal mediated vessel wall integrity changes and hemodynamic stressors), illicit substance use, autoimmune disorders,
198. ACHD: Cardiovascular Multimodality Imaging in Congenital Heart Disease with Dr. Eric Krieger
May 03, 2022
CardioNerds (Daniel Ambinder), ACHD series co-chairs, Dr. Josh Saef (ACHD fellow, University of Pennsylvania) Dr. Daniel Clark (ACHD fellow, Vanderbilt University), and ACHD FIT lead Dr. Jon Kochav (Columbia University) join Dr. Eric Krieger (Director of the Seattle Adult Congenital Heart Service and the ACHD Fellowship, University of Washington) to discuss multimodality imaging in congenital heart disease. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian. Special introduction to CardioNerds Clinical Trialist Dr. Shiva Patlolla (Baylor University Medical Center).
In this episode we discuss the strengths and weaknesses of the imaging modalities most commonly utilized in the diagnosis and surveillance of patients with ACHD. Specifically, we discuss transthoracic and transesophageal echocardiography, cardiac MRI and cardiac CT. The principles learned are then applied to the evaluation of two patient cases – a patient status post tetralogy of Fallot repair with a transannular patch, and a patient presenting with right ventricular enlargement of undetermined etiology.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
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Pearls - Cardiovascular Multimodality Imaging in Congenital Heart Disease
Transthoracic echocardiography (TTE) is the first line diagnostic test for the diagnosis and surveillance of congenital heart disease due to widespread availability, near absent contraindications, and ability to perform near comprehensive structural, functional, and hemodynamic assessments in patients for whom imaging windows allow visualization of anatomic areas of interest.Transesophageal echocardiography (TEE) use in ACHD patients is primarily focused on similar indications as in acquired cardiovascular disease patients: the assessment of endocarditis, valvular regurgitation/stenosis severity and mechanism, assessment of interatrial communications in the context of stroke, evaluation for left atrial appendage thrombus, and for intraprocedural guidance. When CT or MRI are unavailable or contraindicated, TEE can also be used when transthoracic imaging windows are poor, or when posterior structures (e.g. sinus venosus, atrial baffle) need to be better evaluated.Cardiac MRI (CMR) with MR angiography imaging is unencumbered by imaging planes or body habitus and can provide comprehensive high resolution structural and functional imaging of most cardiac and extracardiac structures. Additional key advantages over echocardiography are ability to reproducibly quantify chamber volumes, flow through a region of interest (helpful for quantifying regurgitation or shunt fraction), assess for focal fibrosis via late gadolinium enhancement imaging, and assess the right heart.Cardiac CT has superior spatial resolution in a 3D field of view which makes it useful for clarifying anatomic relationships between structures, visualizing small vessels such as coronary arteries or collateral vessels, and assessing patency of larger vessels (e.
197. Narratives in Cardiology: Empowering the LGBTQIA+ Community of Cardiovascular Patients & Professionals with Dr. Stephen Cook & Dr. Katie Berlacher – Indiana Chapter
Apr 27, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), join Dr. Kara Denby (Interventional cardiology fellow, Cleveland Clinic), Dr. Tony Pastor (ACHD fellow, Harvard Medical School), Dr. Katie Berlacher (Cardiology program director, UPMC), and Dr. Stephen Cook (ACHD cardiologist, Indiana University) to discuss empowering the LGBTQIA+ community of cardiovascular patients & professionals and more in this installment of the Narratives in Cardiology Series. This episode features the Indiana ACC Chapter. Episode introduction and audio editing by CardioNerds Academy Intern, Pace Wetstein.
This discussion was inspired by this perspective piece on ACC.org titled: Finding Our Voices: Building an LGBTQIA+ Community Within Cardiology. To learn more about diversity and equity among the LGBTQIA+ population, check out this webinar organized by the ACC.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
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Claim free CME just for enjoying this episode! There are no relevant disclosures for this episode.
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Tweetorial - Empowering the LGBTQIA+ Community of Cardiovascular Patients & Professionals
https://twitter.com/Gurleen_Kaur96/status/1526334939830034432?s=20&t=wMk75ORn1_KJtMTOY1IAdw
Video version - Empowering the LGBTQIA+ Community of Cardiovascular Patients & Professionals
Coming soon
Production Team
Dr. Gurleen Kaur
Amit Goyal, MD
Daniel Ambinder, MD
196. Case Report: What I C, I Remember: A Case of Acute Heart Failure – Lahey Hospital and Medical Center
Apr 24, 2022
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Sonu Abraham (Cardiology fellow, Lahey Hospital and Medical Center), Dr. Amitoj Singh (Internal Medicine Resident, Lahey Hospital and Medical Center), Dr. Ahmed Ghoneem (Internal Medicine Resident, Lahey Hospital and Medical Center, CardioNerds Academy Chief) and Dr. Aanika Balaji (Internal Medicine Resident, Johns Hopkins) for a scrumptious meal on the Boston Harbor as they discuss a case of a young woman with metastatic melanoma on immune checkpoint inhibitors presenting with dyspnea. The presentation, risk factors, work up and management of patients with immune checkpoint inhibitor induced myocarditis are described. The E-CPR segment is provided by Dr. Sarju Ganatra, the founding director of the cardio-oncology program at Lahey Clinic. CardioNerds Clinical Trialist Dr. Carrie Mahurin (University of Vermont Medical Center) is introduced at the beginning of the episode.
A 41-year-old woman presented with mild dyspnea on exertion and non-productive cough. She had a history of Hashimoto thyroiditis, nodular thyroid s/p resection on levothyroxine, and metastatic melanoma on immune checkpoint inhibitor therapy with ipilimumab and nivolumab. She also had a history of obesity and underwent gastric bypass surgery several years prior. Though she lost weight after the surgery, she regained a significant amount and was 244 lbs with a BMI of 42. Her exam findings were remarkable for tachycardia, bilateral pulmonary rales, elevated JVP, and symmetric pedal edema. Investigations revealed a mild troponin elevation, non-specific EKG changes, and TTE with severely reduced left ventricular function (EF 15%) and a low GLS. Cardiac MRI showed patchy delayed myocardial enhancement in a non-ischemic distribution with marked global hypokinesis and EF of 11%. Endomyocardial biopsy confirmed the diagnosis of immune checkpoint inhibitor (ICI) associated myocarditis. The ICI therapy was discontinued and she was treated with high dose intravenous corticosteroids followed by a prolonged oral steroid taper with clinical improvement and complete recovery of left ventricular function.
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Case Media - immune checkpoint inhibitor myocarditis
Episode Schematics & Teaching
CardioNerds Myocarditis, updated 1.20.21
Pearls - immune checkpoint inhibitor myocarditis
ICI-associated myocarditis has a high mortality rate necessitating a high degree of clinical suspicion. When in doubt, check it out! The initial 4 diagnostic pillars include EKG, troponin, BNP and TTE. Cardiac MRI and endomyocardial biopsy help to confirm the diagnosis.Left ventricular function is normal in 50% of these patients with ICI-associated myocarditis, so the ejection fraction is not a sensitive test for ruling this out.Endomyocardial biopsy should be considered in patients with a high clinical suspicion but negative or ambiguous non-invasive imaging.Early initiation of corticosteroids within 24 hours of presentation is associated with better outcomes.ICIs should be discontinued indefinitely in those with Grade 3 or 4 disease.
Notes - immune checkpoint inhibitor myocarditis
1. Immune checkpoint inhibitors – What are they and why should we as cardiologists know about them?
Immune checkpoint inhibitors (ICI) boost the host immune response against tumor cells by inhibiting the intrinsic brakes of the immune response.There are currently 7 FDA approved drugs in this group: one CTLA-4-blocking antibody called ipilimumab; three PD-1-blocking antibodies [nivolumab, pembrolizumab, and cemiplimab]; and three PD-L1-blocking antibodies [atezolizumab, avelumab, and durvalumab].Like a car,
195. 1st Sanjay V Desai Lecture: Growth Mindset, Power of Yet, & Pursuit of Mastery with Dr. Keri Shafer and Dr. David Hirsh
Apr 06, 2022
The CardioNerds Academy Class of 2021 graduation ceremony kicked off the inaugural Sanjay V Desai Lecture: Growth Mindset, Power of Yet, & Pursuit of Mastery. Join us as Dr. Tommy Das (CardioNerds Academy Program Director), and Dr. Saman Nematollahi (CardioNerds Academy Director of Research) discuss Growth Mindset with Dr. Keri Shafer and Dr. David Hirsh. Terrific acting by Dr. Patrick Zakka, Dr. Teodora Donisan, Dr. Ahmed Ghoneem, and Dr. Jessie Holtzman.
Dr. Sanjay V Desai serves as the Chief Academic Officer, The American Medical Association and is the former Program Director of the Osler Medical Residency at The Johns Hopkins Hospital.
Dr. Keri Shafer is an adult congenital heart disease specialist at Boston Children’s Hospital, and an assistant professor of pediatrics within Harvard Medical School. She completed internal medicine residency at Beth Israel Deaconess Medical Center, before completing cardiology fellowship at UT Southwestern and Adult Congenital and Pulmonary Hypertension subspecialty training at Boston Children’s and BWH.
Dr. David Hirsh is an associate professor of Medicine within Harvard Medical School, as well as the director of the HMS Academy fellowship in medical education and the associate dean of undergraduate medical education.
Relevant disclosures: None
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194. Lipids: Omega-3 Fatty Acids & The Battle Of The Oils with Dr. Pam Taub
Apr 01, 2022
CardioNerds, Amit Goyal, Dr. Tommy Das (Program Director of the CardioNerds Academy and Cardiology fellow at Cleveland Clinic), Dr. Rick Ferraro (Director of CardioNerds Journal Club and Cardiology fellow at the Johns Hopkins Hospital), Dr. Patrick Zakka (CardioNerds Academy Chief fellow of House Jones and Cardiology fellow at UCLA) discuss omega-3 fatty acids & the battle of the oils with Dr. Pam Taub, Director of Step Family Foundation Cardiovascular Rehabilitation and Wellness Center and Professor of Medicine at UC San Diego. Learn all about the different types of omega-3 fatty acids and the differences between prescription omega-3 fatty acids and dietary supplement fish oils. Audio editing by CardioNerds Academy Intern, Shivani Reddy.
This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Relevant disclosures: None
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Pearls - Omega-3 Fatty Acids & The Battle Of The Oils
Coming soon!
Show notes - Omega-3 Fatty Acids & The Battle Of The Oils
Coming soon!
References - Omega-3 Fatty Acids & The Battle Of The Oils
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Sep 10;140(11):e649-e650] [published correction appears in Circulation. 2020 Jan 28;141(4):e60] [published correction appears in Circulation. 2020 Apr 21;141(16):e774].Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186]. Circulation. 2019;139(25):e1082-e1143.Authors/Task Force Members; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk [published correction appears in Atherosclerosis. 2020 Jan;292:160-162] [published correction appears in Atherosclerosis. 2020 Feb;294:80-82]. Atherosclerosis. 2019;290:140-205.Bhatt D, Steg P, Miller M et al., 2019. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. The New England journal of medicine, 380(1), pp.11–22.Budoff M, Bhatt D, Kinninger A et al. Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: final results of the EVAPORATE trial. Eur Heart J. 2020;41(40):3925-3932.Nicholls S, Lincoff A, Garcia M et al. Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk: The STRENGTH Randomized Clinical Trial. JAMA. 2020;324(22):2268-2280.
Guest Profiles
Dr. Pam Taub
Dr. Pam Taub, Professor of Medicine, is the founding director of the StepFamily Foundation Cardiac Rehabilitation and Wellness Center at the University of California, San Diego. Dr. Taub is a leader in preventive cardiology and has authored over one hundred publications, abstracts and book chapters. Dr. Taub is a leader in multiple professional societies, including board membership for the American Society of Preventive Cardiology.
Dr. Patrick Zakka
Dr. Patrick Zakka completed his medical school at th...
193. CCC: Cardiogenic Shock and Valvular Heart Disease with Dr. Paul Cremer
Mar 27, 2022
In this episode we discuss cardiogenic shock due to valvular heart disease. Join Dr. Pranoti Hiremath (Interventional cardiology fellow, Johns Hopkins), Dr. Karan Desai (CN Critical Care Series Co-Chair, Cardiology fellow, University of Maryland), Dr. Yoav Karpenshif (CN Critical Care Series Co-Chair, Chief cardiology fellow, University of Pennsylvania), and Amit Goyal (CardioNerds Co-Founder) as they interview Dr. Paul Cremer (Associate Director of the Cardiac Intensive Care Unit and Associate Director of the Cardiovascular Fellowship at the Cleveland Clinic) in this broad overview of valvular shock. We discuss the nuances in diagnosis, differing presentations and how physical exam, multi-modality imaging, and invasive hemodynamics can inform management. Audio editing by Dr. Gurleen Kaur (Director of the CardioNerds Internship and CardioNerds Academy Fellow).
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
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Pearls and Quotes - Cardiogenic Shock and Valvular Heart Disease
Shock due to valve disease is the result of a structural abnormality that may be temporized with medical therapy and circulatory support devices. However, it is ultimately best treated with a structural solution in the form of either percutaneous valvular therapies or cardiac surgery.When treating a patient with cardiogenic shock with normal or hyperdynamic ventricular function, we should keep a high index of suspicion for valvular disease. The cardiac output may be reduced due to a stenotic lesion “blocking” forward flow or regurgitant lesion causing backward flow.Acute mitral and aortic regurgitation will typically not manifest as a loud murmur on physical exam. The combination of hypotension and rapid flow of regurgitant blood on an “unprepared” cardiac chamber results in rapid equalization of chamber pressures, shortening the intensity and duration of the murmur. On transthoracic echocardiogram, for instance with acute MR, color Doppler may not show a large turbulent jet, and thus the MR may be underestimated or not appreciated at all.Echocardiography is critical to understand the etiology and severity of valvular shock, and invasive hemodynamics are often needed to guide medical and mechanical interventions.In multi-valve disease with severe aortic stenosis and functional mitral regurgitation, we typically treat the aortic stenosis first, since the mitral regurgitation may improve from the reduction in afterload associated with treating aortic stenosis.
Show notes - Cardiogenic Shock and Valvular Heart Disease
1. Shock due to valve disease arises due to a structural problem that may be temporized with medical therapy and circulatory support devices, but is ultimately best treated with a structural solution in the form of either percutaneous valvular therapies or cardiac surgery.
Stabilizing therapies for acute mitral regurgitation include afterload reduction with vasodilators, diuresis as needed to reduce pulmonary edema, and mechanical circulatory support including intra-aortic balloon pumps.Therapies for acute aortic regurgitation are typically more limited and include vasopressors such as epinephrine. Bradycardia should be avoided with agents such as dobutamine or temporary pacing to reduce time in diastole. Temporary mechanical circulatory support options are limited in the setting of acute AR, though case reports of techniques such as LAVA ECMO (left atrial venoarterial extracorpeal membr...
192. Guidelines: 2021 ESC Cardiovascular Prevention – Question #6 with Dr. Melissa Tracy
Mar 25, 2022
The following question refers to Section 4.8 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern student Dr. Christian Faaborg-Andersen, answered first by UCSF resident Dr. Jessie Holtzman, and then by expert faculty Dr. Melissa Tracy.
Dr. Tracy is a preventive cardiologist, echocardiographer, Director of Cardiac Rehabilitation, and solid organ transplant cardiologist at Rush University.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #6
A 62-year-old man with a history of non-obstructive coronary artery disease, heart failure with reduced ejection fraction (EF 30-35%), stage III chronic kidney disease, and type II diabetes mellitus presents to your clinic to establish care. His only medications are aspirin 81 mg daily and metformin 1000 mg BID, which he has taken since being diagnosed with diabetes mellitus 5 years ago. His hemoglobin A1c is 6.8%. What changes would you recommend to his medications at this time?A. Start glipizideB. Start saxagliptinC. Start empagliflozinD. No changes
Answer #6
The correct answer is C – start empagliflozin.The Trials involving SGLT-2 inhibitors and GLP-1R agonists have shown cardiovascular benefits independent of glycemic control and metformin use.The ADA recommends metformin as a first-line therapy for all patients with type 2 DM. The ESC also recommends metformin as first-line therapy but only in patients without ASCVD, CKD, or HF (Class I, LOE B). If a patient has ASCVD, metformin can be considered (Class IIa, LOE B). Rather, for those patients with type 2 DM and ASCVD, the ESC recommends the use of GLP-1R agonist or SGLT-2 inhibitors with proven outcome benefits to reduce CV and/or cardiorenal outcomes (Class I, LOE A). Additionally, for those with type 2 DM and either CKD or HFrEF, the ESC recommends the use of SGLT-2 inhibitor to improve outcomes (Class I, LOE A).In contrast to the ADA, the view of the ESC is that metformin should be considered but is not mandatory first-line treatment in patients with diabetes and ASCVD or evidence of target organ damage. The initiation of metformin in such patients should not forego or delay the initiation of evidence-based SGLT2 inhibitors or GLP-1RAs.Therefore, the next best step for our patient is to start an SGLT-2 inhibitor given his history of CAD, HF, and CKD. While this patient’s A1c goal is within the range recommended for patients with Type 2 DM and ASCVD (<7%), given his CAD, HF, and CKD an SGLT-2 inhibitor should still be added.Saxagliptin is a DPP-4 inhibitor, a class of drugs that showed no effect of MACE but increased risk of HF hospitalization in patients with DM and existing.Lifestyle management is a top priority for ASCVD prevention and management of DM. Lifestyle intervention lowers future microvascular and macrovascular risks as well as mortality in the longer term. Intensive lifestyle changes with low-calorie diets and mean weight losses in the region of 10 kg leads to remission of type 2 DM in around 46% of cases at 1 year and 36% by 2 years. Smoking cessation, a diet low in saturated fat and high in fiber, aerobic physical activity, strength training, and reduction in energy intake for weight optimization are all recommended for patient with diabetes mellitus (Class I).Main TakeawayIn patients with Type 2 DM and ASCVD or end organ dysfunction, SGLT-2 inhibitors or GLP-1R agonists should be recommended regardless of background therapy or glycemic control. For patients with type 2 diabetes mellitus and CKD or HFrEF, SGLT-2 inhibitor is recommended.Guideline LocationSection 4.8.1, Pages 3289-90.
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191. Guidelines: 2021 ESC Cardiovascular Prevention – Question #5 with Dr. Laurence Sperling
Mar 25, 2022
The following question refers to Section 4.10 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern student Dr. Christian Faaborg-Andersen, answered first by UCSD fellow Dr. Patrick Azcarate, and then by expert faculty Dr. Laurence Sperling.
Dr. Laurence Sperling is the Katz Professor in Preventive Cardiology at the Emory University School of Medicine and Founder of Preventive Cardiology at the Emory Clinic. Dr. Sperling was a member of the writing group for the 2018 Cholesterol Guidelines, serves as Co-Chair for the ACC's Cardiometabolic and Diabetes working group, and is Co-Chair of the WHF Roadmap for Cardiovascular Prevention in Diabetes.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #5
The European Society of Cardiology Prevention guidelines currently recommend that low-dose colchicine (0.5mg/day) may be considered for the primary prevention of cardiovascular disease.A. TrueB. False
Answer #5
The correct answer is False. The correct answer is False.The European Society of Cardiology recommends that low-dose colchicine may be considered as an adjunctive therapy for secondary rather than primary prevention of cardiovascular disease in individuals whose risk factors are otherwise insufficiently controlled (Class IIb, LOE A). A broad evidence base currently supports that inflammation has pro-atherosclerotic effects and that reducing inflammation may reduce atherogenesis in high-risk patients.The initial LoDoCo trial in 2013 first demonstrated a 10.7% absolute risk reduction in acute coronary syndrome, out of hospital cardiac arrest, and non-cardioembolic ischemic stroke with daily low-dose colchicine; however, results were clouded by small sample size. Subsequently, the CANTOS trial in 2017 demonstrated a 15% relative reduction in non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death with Canakinumab, an anti-inflammatory monoclonal antibody inhibitor of interleukin-1. More recently, the COLCOT trial in 2019 studying patients with recent AMI and LoDoCo2 trial in 2021 studying patients with stable chronic CAD both demonstrated reductions in myocardial infarction, cardiovascular mortality, CVA, and ischemia-driven revascularization with colchicine 0.5mg/day. In the LoDoCo2 trial, stable CAD was defined either angiographically, by coronary CT, CAC >400, or history of CABG >10 years prior with evidence of failed grafts or angioplasty since that time.In high-risk individuals with stable ischemic heart disease, the most recent evidence suggests that once daily low dose colchicine may reduce myocardial infarction and other ischemic events. Future studies may assess the biochemical markers including the trend of lipids and inflammatory markers to identify subpopulations that may benefit most from this therapy.Main Takeaway:Based upon the 2021 ESC Prevention Guidelines, clinicians may consider initiating low-dose colchicine (0.5mg/day) for secondary prevention of cardiovascular disease, particularly if other risk factors are insufficiently controlled or if recurrent CVD events occur despite optimal therapy.Guideline Location: Section 4.10, page 3291.
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190. Guidelines: 2021 ESC Cardiovascular Prevention – Question #4 with Dr. Roger Blumenthal
Mar 24, 2022
The following question refers to Section 4.7 and figure 16 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Student Dr. Shivani Reddy, answered first by Fellow at Johns Hopkins Dr. Rick Ferraro, and then by expert faculty Dr. Roger Blumenthal.Dr. Roger Blumenthal is professor of medicine at Johns Hopkins where he is Director of the Ciccarone Center for the Prevention of Cardiovascular Disease. He was instrumental in developing the 2018 ACC/AHA CV Prevention Guidelines. Dr. Blumenthal has also been an incredible mentor to CardioNerds from our earliest days.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #4
Ms. K.M. is a 40-year-old woman presenting to the outpatient clinic for a routine physical exam required for her employment as an airline stewardess. She states she has been in her usual good health but does experience occasional headaches and lightheadedness while in flight. On exam her BP was noted to be 170/90. The diagnosis of hypertension is confirmed during a subsequent clinic visit. What would be the most appropriate initial therapy recommendation(s) for Ms. K.M.?A. Initiate single drug therapy with a beta-blocker.B. Discuss and initiate lifestyle interventionsC. Initiate two-drug combination therapy with a thiazide-like diuretic, BB, CCB, or an ARB.D. Both B and C
Answer #4
The correct answer is D.
Both B (lifestyle interventions) and C (initial combination therapy) are appropriate at this time.
Lifestyle interventions are indicated for all patients with high-normal BP or hypertension because they can delay the need for drug treatment or complement the BP-lowering effect of drug treatment (Class 1). Moreover, most lifestyle interventions have health benefits beyond their effect on BP.
Single-drug therapy will rarely achieve optimal BP control. Therefore, initial antihypertensive therapy with a combination of two drugs, preferably as a single-pill combination, is recommended for the management of HTN (Class 1). The only exceptions would be patients with a baseline BP close to the recommended target, who might achieve that target with a single drug, or very old (>80 years) or frail patients who may better tolerate a gentler reduction of BP.
Five major classes of BP-lowering drug therapy have shown benefit in reducing CV events; angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics.
A combination of an ACE inhibitor or ARB with a CCB or thiazide/thiazide-like diuretic is the preferred initial therapy for most patients with hypertension (Class 1). For those in whom treatment requires escalation to three drugs, a combination of an ACE inhibitor or ARB with a CCB and a thiazide/thiazide-like diuretic should be used (Class 1).
Resistant hypertension is defined as BP being uncontrolled despite treatment with optimal or best-tolerated doses of three or more drugs including a diuretic, and confirmed by ABPM or HBPM. Spironolactone is the most effective drug for lowering BP in resistant hypertension when added to existing treatment; however, the risk of hyperkalaemia is increased in patients with CKD. When spironolactone is not tolerated, amiloride, alpha-blockers, beta-blockers, or centrally acting drugs, such as clonidine, have evidence supporting their use. Renal denervation and device-based therapy may be considered for specific cases.
Beta-blockers should be used when there is a specific indication (e.g. angina, post myocardial infarction, arrythmia, HFrEF, or as an alternative to an ACE inhibitor or ARB in women of child-bearing potential). Combinations of an ACE inhibitor and an ARB are not recommended because of no added ben...
189. Guidelines: 2021 ESC Cardiovascular Prevention – Question #3 with Dr. Kim Williams
Mar 23, 2022
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by medicine resident CardioNerds Academy House Chief Dr. Ahmed Ghoneem, and then by expert faculty Dr. Kim Williams.
Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016).
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #3
Mrs. B is a 56-year-old African American woman with a past medical history significant for type 2 diabetes (HbA1C 7.6) and hypercholesterolemia. Her calculated ASCVD risk score today is 12.5% and her BMI is 24kg/m2. She is concerned about her high cholesterol levels despite being on a statin and feels that her diet is “not healthy enough.” She is interested in making dietary changes to help reduce her ASCVD risk. Which of the following recommendations is appropriate?A. Sodium restriction to <3g /day will be of no benefit because she is not hypertensive.B. Isocaloric substitution of saturated fat with polyunsaturated fat is associated with reduction of CHD risk.C. Dietary fiber intake is associated with GI benefits but has no CV risk reduction benefit.D. Supplementing diet with vitamins A, B, C and E helps reduce ASCVD risk.
Answer #3
The correct answer is B.Risk of CHD is reduced when dietary saturated fats are replaced with other foods having similar caloric values. The greatest reduction was observed when saturated fats were isocalorically replaced with polyunsaturated fats (↓25%), followed by monounsaturated fats (↓15%) and carbohydrates from whole grains (↓9%). This is a class 1a recommendation in the ESC guidelines and a class IIa recommendation in the 2019 ACC/AHA guidelines. Conversely, increased trans fatty acid intake is associated with increased CHD risk. A regulation of the European Union (EU) Commission has set the upper limit of trans fats to 2 g per 100 g of fat. The ACC/AHA guidelines recommend that the intake of trans fats should be avoided (a class III: harm).Choice A is incorrect because dietary sodium restriction is recommended not only for control of blood pressure, but also for reduction of ASCVD risk. In a meta-analysis, salt reduction of 2.5 g/day resulted in a 20% reduction of ASCVD events (RR 0.80). Reduction of salt intake is a class 1 recommendation in the ESC guidelines compared to a class IIa recommendation in the 2019 ACC/AHA guidelines.Choice C is incorrect because a 10 g/day higher fiber intake was associated with a 16% lower risk of stroke (RR 0.84) and a 6% lower risk of type 2 DM (RR 0.94). A high fiber intake may reduce postprandial glucose responses after carbohydrate-rich meals and also lower triglyceride levels. The Mediterranean diet is rich in fiber (it includes high intakes of fruits, vegetables, pulses and wholegrain products) and is a class I recommendation.Choice D is incorrect because while vitamin supplementation has been associated with reduction in ASCVD risk in observational studies, intervention trials have failed to show any benefit. Main Takeaway:A healthy diet is recommended as a cornerstone of CVD prevention in all individuals, independent of their underlying co-morbidities. Replacing saturated with unsaturated fats, reducing salt intake, and choosing a more plant-based diet that is rich in fiber can lower risk of CVD.Guideline LocationSection 4.3.2, Page 3270
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188. Guidelines: 2021 ESC Cardiovascular Prevention – Question #2 with Dr. Allison Bailey
Mar 22, 2022
The following question refers to Section 3.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern student Dr. Adriana Mares, answered first by Brigham & Women’s medicine intern & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Allison Bailey.Dr. Bailey is an advanced heart failure and transplant cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology's Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #2
Mr. Early M. Eye is a 55-year-old man with a history of GERD who is seeing you in clinic as he is concerned about his family history of early myocardial infarction and would like to discuss if he should be taking a statin for cardiovascular prevention. He has never smoked tobacco. His 10-year CVD risk is estimated to be 8%. Which imaging modality is recommended by the ESC guidelines to reclassify his CVD risk?A. Coronary Artery Calcium (CAC) scoringB. Echocardiography C. Ankle brachial index D. Contrast enhanced computed tomography coronary angiography (CCTA)E. None of the above
Answer #2
The correct answer is A.Coronary artery calcium (CAC) scoring can reclassify CVD risk upwards and downwards and should specifically be considered in patients with calculated risk scores that are around decision thresholds. CAC scores which are high-than-expected for age and sex increase estimated future CVD risk. Notably, CAC scoring may also be used to “de-risk” if CAC is absent or lower-than-expected. The 2021 ESC Prevention Guidelines give a Class IIb (LOE B) recommendation to consider CAC scoring to improve risk classification around treatment decision thresholds. However, one limitation of CAC is that it does not provide direct information on total plaque burden or stenosis severity. In addition, there is also a Class IIb (LOE B) recommendation to use plaque detection by carotid ultrasound as an alternative when CAC scoring is unavailable or not feasible. Plaque assessed through carotid ultrasound is defined as presence of wall thickening that is >50% greater than the surrounding vessel wall or a focal region with intima-media thickness measurement >1.5mm that protrudes into the lumen.Similar to the ESC Prevention Guidelines, the 2019 ACC/AHA guidelines on primary prevention of CVD also have a Class IIa recommendation for using CAC score, and explicitly mention its use for adults at intermediate risk (>7.5% to <20% 10-year ASCVD risk) with cut-offs including >100 Agatson units to reclassify risk upwards and CAC of 0 to reclassify risk downwards. However, the guidelines also mention that clinicians should not down-classify risk in patients who have CAC of 0 if they are current smokers, have diabetes, have a family history of ASCVD, or have chronic inflammatory conditions. Furthermore, the 2018 ACC/AHA Cholesterol guidelines have a Class IIa recommendation that if CAC is 0, it is reasonable to withhold statin therapy and reassess risk in 5 to 10 years, as long as higher risk conditions that we just discussed are absent. If CAC is 1-99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age.Choice B is incorrect. Echocardiography is not recommended to improve CV risk prediction due to lack of convincing evidence that it improves CVD risk reclassification.Choice C is incorrect. While the 2013 ESC guidelines mentioned that ABI may be considered as a risk modifier in CVD risk estimation, the newer 2021 guidelines state that ankle brachial index has limited potential in terms of reclassification risk, though an individual patient data meta-analysis showed th...
187. Guidelines: 2021 ESC Cardiovascular Prevention – Question #1 with Dr. Eugene Yang
Mar 21, 2022
This question refers to Sections 3.2 and 3.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern, student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.
Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.
The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.
Question #1
A 48-year-old Pakistani woman with rheumatoid arthritis comes to your clinic asking how she can reduce her risk of ASCVD. Her mother died of an MI at age 45, her father is healthy at age 79. Her calculated 10-year risk based on SCORE2 is 3%. SBP is 120 mmHg, LDL is 120 mg/dL. What is the next best step? A. Order an echocardiogram B. Schedule a follow-up appointment in 1 year C. Discuss initiating a statin D. Repeat lipid panel in 3-5 years
Answer #1
Answer: C. Discuss Initiating a statin The absolute benefit derived from risk factor modification depends on the absolute risk of CVD and the absolute improvements in each risk factor category. Risk factor treatment recommendations are based on categories of CVD risk (“low-to-moderate”, “high”, and “very high”). The cut-off risk levels for these categories are numerically different for various age groups to avoid undertreatment in the young and to avoid overtreatment in the elderly. As age is a major driver of CVD risk, but lifelong risk factor treatment benefit is higher in younger people, the risk thresholds for considering treatment are lower for younger people as per the ESC guidelines. Treatment decisions should be made with shared decision-making valuing patient preference. Option A is INCORRECT- there is a lack of convincing evidence that echocardiography improves CVD risk reclassification, and it is NOT recommended to improve CV risk prediction. (Class III, LOE B) Option B is INCORRECT- simply doing nothing is not appropriate for this patient with elevated CVD risk. Option C is CORRECT- This patient has a seemingly low 10-year CVD risk based on SCORE 2 of 3% and her SBP is controlled; however, given her age she is considered as having high CVD risk, therefore treatment should be considered. Stepwise approach involves targeting LDL <100 (class IIa) so initiating a statin would be appropriate. This patient also carries several risk enhancing modifiers including Pakistani ethnicity, family history of premature CVD, and inflammatory comorbidity. All patients should be counseled on smoking cessation, lifestyle modifications, and target SBP <160 mmHg. Option D is INCORRECT- repeating a lipid panel without risk factor modification will not change treatment recommendations for this patient with elevated CVD risk. Main Takeaway In summary, when a patient <50 years old without established ASCVD has an estimated 10-year risk 2.5 to <7.5% they are considered high CVD risk and risk factor treatment should be considered. Risk modifiers should also be taken into consideration. *Of note- ACC/AHA guidelines recommend the ASCVD risk calculator to estimate 10-year risk and do not restructure CVD risk groups according to age groups. High risk in the ACC/AHA guidelines is considered to be >20%. Guideline Location Table 5 and Figure 5, Page 32513.2.3.4, Page 32533.2.3, Figure 6 page 32523.3, Pages 3258-3259
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186. Case Report: Coronary Artery Bypass Grafting: An Iatrogenic Left to Right Cardiac Shunt – SUNY Downstate
Mar 20, 2022
CardioNerds (Amit Goyal and Daniel Ambinder) and guest host, Dr. Priya Kothapalli (UT Austin fellow and CardioNerds Ambassador), join SUNY Downstate cardiology fellows, Dr. Eric Kupferstein and Dr. Gautham Upadhya to discuss a case about a patient who had coronary artery bypass grafting that was complicated by a LIMA grafted to the great cardiac vein. Dr. Alan Feit (Professor of Medicine, SUNY Downstate) provides the E-CPR for this episode. Dr. Moritz Wyler von Ballmoos (Director, robotic cardiac and vascular surgery for Houston Methodist Cardiovascular Surgery Associates) provides a special perspective regarding coronary artery bypass grafting as it relates to this case. Episode introduction with CardioNerds Clinical Trialist Dr. Jana Lovell (Johns Hopkins).
Left Internal Mammary Artery (LIMA) to Left Anterior Descending (LAD) artery anastomosis is the cornerstone of Coronary Artery Bypass Graft (CABG) surgery. Anastomosis of the LIMA to the Great Cardiac Vein (GCV) is a known but rare complication of the surgery. Currently there are no clear guidelines in regard to further management. We report a case of a LIMA to GCV anastomosis managed with a drug eluting stent (DES) to the mid LAD after ruling out a significant left to right heart shunt.
Jump to: Case media - Case teaching - References
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Case Media - Coronary Artery Bypass Grafting: An Iatrogenic Left to Right Cardiac Shunt
Angiography
Episode Schematics & Teaching - Coronary Artery Bypass Grafting: An Iatrogenic Left to Right Cardiac Shunt
Pearls - Coronary Artery Bypass Grafting: An Iatrogenic Left to Right Cardiac Shunt
Listen to the patient's story. The patient determines when the angina is no longer stable angina.The placebo effect of our interventions should not be discounted.LIMA to GCV anastomosis creates a left to right cardiac shunt. A Qp:Qs greater than 1.5 signifies a significant shunt.Increasing the pressure in the coronary sinus may actually be beneficial to the patient.LIMA-LAD is remains the most efficacious and long lasting graft but why not other arterial grafts?
Notes - Coronary Artery Bypass Grafting: An Iatrogenic Left to Right Cardiac Shunt
Iatrogenic anastomosis of the LIMA to the GCV is a rare but noted complication of CABG surgery. Review of the literature has reported under 40 such cases of arteriovenous fistula formation in the coronary system. Detection of the anastomosis generally stems from recurrent angina which can be attributed to unresolved ischemia or coronary steal syndrome but also can be detected with new heart failure (namely right sided heart failure due to left to right shunting). Diagnosis is usually made with coronary angiography, but CT coronary angiography has also been reported. Due to the rarity of this complication, no clear guidelines are in place directing the management leaving it to the discretion of the various Heart Teams. Evaluating for signs of heart failure and/or ischemia, and measuring the Qp:Qs have been the most common signs directing management. Various options are available for closing the fistula and include coil or balloon embolization, vascular plugs, venous ligation or a covered stent. Redoing the surgery is also an option. Spontaneous closure of the fistula has also been reported. Lastly, if redo surgery is not performed then regardless of fistula closure, coronary intervention for the native diseased artery may be pursued to relieve symptoms.
References
Boden et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007 Apr 12;356(15):1503-16. doi: 10.1056/NEJMoa070829. Epub 2007 Mar 26. PMID: 17387127.
185. ACHD: Tetralogy of Fallot with Dr. George Lui
Mar 16, 2022
CardioNerds (Daniel Ambinder), ACHD series co-chair, Dr. Josh Saef (ACHD fellow at University of Pennsylvania), and ACHD FIT lead Dr. Charlie Jain (Mayo Clinic) join ACHD expert Dr. George Lui (Medical Director of The Adult Congenital Heart Program at Stanford and Program Director for the ACGME adult congenital heart disease fellowship at Stanford) to discuss Tetrology of Fallot. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
Tetralogy of Fallot (ToF) is the most common cyanotic heart disease and one of the most common congenital heart diseases that we see in adults overall. The anatomy includes a ventricular septal defect (VSD), an overriding aorta, and infundibular hypertrophy with subpulmonic +/- pulmonic valvular +/- supravalvular stenosis, which causes severe RV outflow obstruction and subsequent RV hypertrophy. Patients require surgery during childhood, which includes patching the VSD and relieving RV outflow obstruction. This results in pulmonic regurgitation (usually severe) and patients can live with this for decades. Adults with ToF commonly will require pulmonic valve replacement, potential relief of subvalvular or supravalvular stenoses, and tricuspid valve repair (for functional tricuspid regurgitation caused by RV dilation). These patients are at increased risk of atrial and ventricular arrhythmias and may warrant prophylactic ICDs.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Tetralogy of Fallot
Tetralogy of Fallot is the most common cyanotic heart disease and the 4 anatomic features are: VSD, infundibular hypertrophy (with RVOT obstruction), overriding aorta, and RV hypertrophy. The most common lesion you will see in adults with repaired Tetralogy of Fallot is pulmonic regurgitation.Pulmonic regurgitation (PR) can be easy to miss on exam as the murmur is brief and even shorter when the PR is severe. In patients with PR and aortic regurgitation, remember PR is clearest when laying supine, in comparison to aortic regurgitation which is loudest while leaning forward.Patients with ToF may also have coronary anomalies (e.g. LAD off RCA), right-sided aortic arches, and also left-sided heart disease (LV diastolic or systolic dysfunction).Patients with ToF are at risk for atrial and ventricular arrhythmias, and clinicians should consider prophylactic ICD for those with multiple risk factors for sudden death (e.g. QRS >180ms, scar on MRI).In all patients with congenital heart disease, inspection is a key part of the physical exam (e.g. right thoracotomy could clue you into a prior BTT shunt) and in patients with prior BTT shunts and/or prior brachial cut-downs (look in the antecubital fossa for scars), radial arterial access is discouraged.
Show notes - Tetralogy of Fallot
LesionTTETEECardiac MRICardiac CTTetralogy of Fallot(1) Routine assessment of RV and LV size and function (2) Routine semiquantitative assessment of pulmonic valve regurgitation (3) Evaluation of PVR/conduit gradients,
184. CardioNerds Rounds: Challenging Cases of Cardiovascular Prevention with Dr. Martha Gulati
Mar 14, 2022
CardioNerds Rounds Co-Chairs, Dr. Karan Desai and Dr. Natalie Stokes and CardioNerds Academy Fellow, Dr. Najah Khan, join Dr. Martha Gulati – President-Elect of the American Society for Preventive Cardiology (ASPC) and prior Chief of Cardiology and Professor of Medicine at the University of Arizona – to discuss challenging cases in cardiac prevention. As an author on numerous papers regarding cardiac prevention and women’s health, Dr. Gulati provides many prevention pearls to help guide patient care. Come round with us today by listening to the episodes now and joining future sessions of #CardsRounds!
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Cases discussed and Show Notes • References • Production Team
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Show notes - CardioNerds Rounds: Challenging Cases of Cardiovascular Prevention with Dr. Martha Gulati
Case #1 Synopsis:
A 55-year-old South Asian woman presents to prevention clinic for an evaluation of an elevated LDL-C. Her prior history includes hyperlipidemia, hypertension, obesity, and pre-eclampsia. She was told she had “high cholesterol” a few years prior and would need medication. She started exercising regularly and cut out sweets from her diet. Before clinic, labs showed: Total Cholesterol (mg/dL) of 320, HDL 45, Triglycerides 175, and (directly measured) LCL-C 180. Her Lipoprotein(a) is 90 mg/dL (ULN being ~ 30 mg/dL). Her HbA1C is 5.2% and her 10-year ASCVD Risk (by the Pooled Cohorts Equation) is 5.4%. Her recent CAC score was 110. She prefers not to be on medication and seeks a second opinion.
Takeaways from Case #1
As Dr. Gulati notes, in the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, South Asian ethnicity is considered a “risk enhancing factor.” The pooled cohort equations (PCE) may underestimate risk in South Asians. Furthermore, risk varies within different South Asian populations, with the risk for cardiovascular events seemingly higher in those individuals of Bangladeshi versus Pakistani or Indian origin. There are multiple hypotheses for why this may be the case including cultural aspects, such as diet, physical activity, and tobacco use. A better understanding of these factors could inform targeted preventive measures.In the same 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease mentioned above, history of an adverse pregnancy outcome (APO) increases later ASCVD risk (e.g., preeclampsia) and is also included as a “risk-enhancing factor.” Studies have shown that preeclampsia is an independent risk factor for developing early onset coronary artery calcification. Recent data has shown that the risk for developing preeclampsia is not the same across race and ethnicity, with Black women more likely to develop preeclampsia. Black women also had the highest rates of peripartum cardiomyopathy, heart failure, and acute renal failure. After adjustment for socioeconomic factors and co-morbidities, preeclampsia was associated with increased risk of CVD events in all women, the risk was highest among Asian and Pacific Islander women. Listen to Episode #174. Black Maternal Health with Dr. Rachel Bond to learn more about race-based disparities in cardio-obstetric care and outcomes.Our patient thus has multiple risk-enhancing factors to help in shared decision making and personalize her decision...
183. Cardio-Obstetrics: The Fourth Trimester: Postpartum and Long-term Cardiovascular Care after Hypertensive Disorders of Pregnancy with Dr. Malamo Countouris and Dr. Alisse Hauspurg
Mar 06, 2022
CardioNerds (Amit Goyal), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), and episode lead Dr. Priya Freaney (Northwestern University cardiology fellow) discuss “The Fourth Trimester” with Dr. Malamo Countouris and Dr. Alisse Hauspurg, from the University of Pittsburgh Departments of Cardiology and Obstetrics and Gynecology, respectively. We discuss the cardiovascular considerations after adverse pregnancy outcomes in the postpartum and long-term follow-up periods. The discussion is focused mainly on hypertensive disorders of pregnancy (HDP), guided by a series of clinical vignettes. We cover a wide range of topics from cardiovascular complications and management considerations in the immediate postpartum period after a HDP, postpartum outpatient follow-up, long term cardiovascular morbidity related to HDP and related preventive strategies, contraceptive considerations for the cardiologist, and interdisciplinary care management pearls for cardiologists working in a cardio-obstetrics team.
Notes • References • Guest Profiles • Production Team
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Pearls - The Fourth Trimester
Blood pressures >160/110 should be treated like a true emergency during pregnancy and the postpartum period, as the cerebrovascular circulation is more sensitive to hypertension, due to hormonal changes related to pregnancy.Women with pre-eclampsia are at higher risk for peripartum cardiomyopathy. Have a low threshold to do a clinical heart failure evaluation (i.e., natriuretic peptides, echocardiogram), and administer diuretics as appropriate to improve volume status and blood pressure.Women with HDP should have their blood pressures monitored closely after discharge, ideally with a home BP monitoring program, as they can have exacerbations of their HTN for up to 2 weeks postpartum.The American Rescue Plan Act of 2021 included a landmark policy to extend postpartum Medicaid coverage up to a year postpartum (from 60 days).Remember to take a reproductive history for every woman you see in cardiology clinic! This can be done in one minute. At a minimum, include obstetric history [number of pregnancies, outcome of each pregnancy, gestational age and weight at delivery, pregnancy complications (HDP, GDM, etc), and delivery method] and menopausal history (age at menarche, age at menopause).The Pooled Cohort Equations may underestimate ASCVD risk for a woman who has had pregnancy complications or premature menopause – consider obtaining a CAC score to aid in risk-stratification in middle-aged women who may have underestimated risk.Low dose aspirin during pregnancy in women who have risk factors for pre-eclampsia reduces the risk of development of HDP by 15-20%.
Quotables - The Fourth Trimester
“Some of our traditional approaches to caring for women in the postpartum period just aren’t realistic…we need to think about how we can improve care from a policy standpoint to ensure women have access to care and think about how we deliver care.” – Dr. Alisse Hauspurg
“Silos are never good. Cardio-obstetrics is a space where you really want to have open communications, be truly collaborative – taking into consideration the expertise of multiple disciplines…because it’s really hard to do it alone.” – Dr. Malamo Countouris
Show notes - The Fourth Trimester
For more on hypertensive disorders of pregnancy enjoy:
Episode #128: Cardio-Obstetrics: Hypertensive Disorders of Pregnancy with Dr. Jennifer LeweyEpisode #66: Case Report: Severe Pre-eclampsia & Cardio-Obstetrics – UPMC
Hypertensive Disorders of Pregnancy
1. What are some of the immediate postpartum cardiovascular risks and complications following a hypertensive disorder of pregnancy (H...
182. Case Report: Dyspnea with an LVAD: A Tale of Hypoxia and Hemodynamics – Temple University
Feb 27, 2022
CardioNerds (Amit Goyal & Karan Desai) join Dr. Matthew Delfiner (Cardiology fellow, Temple University Hospital) and Dr. Katie Vanchiere (Internal medicine resident, Temple University Hospital) in the beautiful Fairmount Park in Philadelphia. They discuss a case of a 53-year-old man with an LVAD who presents with progressive dyspnea since LVAD implant due to right-to-left shunting due to a PFO. Dr. Val Rakita (Assistant professor of medicine and advanced heart failure and transplant specialist at Temple University Hospital) provides the E-CPR for this episode. Episode introduction by CardioNerds Clinical Trialist Dr. Anthony Peters (Duke Heart Center). This case has been published by Circulation: Heart failure. See Invasive Hemodynamic Study Unmasks Intracardiac Shunt With Ventricular Assist Device.
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Disclosures: NoneJump to: Pearls - Notes - References
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Case Summary - Dyspnea with an LVAD: A Tale of Hypoxia and Hemodynamics
A 53-year-old man with an LVAD placed 3 months prior presents with progressive dyspnea since LVAD implant, though it has acutely worsened over the past 2 weeks. Two weeks ago, he had a hemodynamic and echocardiographic ramp study, where the LVAD speed was increased. By increasing the speed, his LV was more adequately decongested, and flow improved. In the Emergency Department, he was hypoxic on room air, and remained so with escalation ultimately with intubation. Even then he remained severely hypoxic requiring cannulation to veno-venous ECMO.
Chest imaging was normal, and LVAD parameters were normal without any alarms. An astute clinician noticed that when the patient became hypertensive, his oxygen saturation improved. A subsequent echocardiogram revealed a patent foramen ovale, with right to left shunting. The patient then went to the cath lab, where simultaneous right atrial and left atrial pressures and oxygen pressures were measured, along with trans-esophageal echocardiography, while adjusting LVAD speed. It became evident that right-to-left shunting occurred only when there was high LVAD speed and low peripheral blood pressure. Essentially, faster LVAD speeds (sucking blood from the LV) and low systemic blood pressure (reducing LV afterload) increased right to left shunting by decreasing the left atrial pressure relative to the right atrial pressure. The PFO was closed at that time, drastically improving oxygenation. He was decannulated and extubated the following day.
Invasive Hemodynamic Study Unmasks Intracardiac Shunt With Ventricular Assist Device | Circulation: Heart Failure (ahajournals.org)
Episode Teaching -Dyspnea with an LVAD: A Tale of Hypoxia and Hemodynamics
Pearls
PFOs are present in up to 25% of individuals, including those with LVADs.LV unloading, and therefore LA decompression, depends on both LVAD speed and systemic vascular resistance.Blood pressure dependent hypoxia may be suggestive of a right-to-left intracardiac shunt.Hypoxia refractory to mechanical ventilation should raise suspicion for intracardiac shunt.Patients with LVADs can suffer from the same diseases that anyone can.
Notes - Dyspnea with an LVAD: A Tale of Hypoxia and Hemodynamics
1. What factors influence LVAD flow?
Factors that influence LVAD flow include pump speed, blood pressure, volume status, RV function, cardiac rhythm, and some other variables. The faster the pump is spinning, the more flow you should provide (to an extent). However, if your LV is underfilled, either from systemic hypovolemia or an RV not providing the needed LV preload, then you have no blood to flow! If you have high systemic vascular resistance, then you will have less forward flow,
181. Aortic Stenosis and the Story of TAVR – Historical Perspective & Future Directions with Dr. Jon Resar
Feb 21, 2022
CardioNerds, Daniel Ambinder and CardioNerds Academy Program Director, Dr. Tommy Das (Cardiology fellow, Cleveland Clinic), Dr. Jacqueline Latina (Structural heart fellow, Johns Hopkins) discuss aortic stenosis and the story of TAVR from both the historical perspective and in terms of future directions with Dr. Jon Resar, Professor of Medicine and Director of the Adult Catheterization Laboratory and Interventional Cardiology at the Johns Hopkins Hospital. This episode is brought to you for Heart Valve Disease Awareness Day. Audio editing by CardioNerds Academy Intern, Shivani Reddy.
As many as 11 million Americans have heart valve disease (HVD)—a potentially disabling and deadly disease—yet 3 out of 4 Americans know little to nothing about heart valve disease. Learn more about valve disease.
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls and Quotes - Aortic Stenosis and the Story of TAVR
In the previous century, patients with severe aortic stenosis who were treated “medically” had 50% mortality over 2 years after developing symptoms. Balloon aortic valvuloplasty was initially touted as extremely “efficacious” for aortic stenosis but follow-up studies showed that the improvement in symptoms were not durable, and long-term prognosis was dismal.
The PARTNER Trial started enrolling in 2007 in extreme risk patients – patients who were not surgical candidates. In 2010, the PARTNER trial was published and TAVR blew away the “standard of care” in inoperable patients at the time, cutting outcomes in half (composite of death and repeat hospitalization). The PARTNER trial studied balloon expandable intra-annular valve implantation. The CoreValve trial studied self-expanding supra-annular valve implantation and was published in 2014.
The “Heart Team” approach entails collaborative decision making between cardiologists and cardiac surgeons to personalize management for patients.
Both intra-annular and supra-annular valves show non-inferior outcomes to surgery in intermediate and low risk patients.
Revascularization prior to TAVR is an evolving arena; the trend has been interventionalists performing fewer PCIs prior to TAVR given the benefit is not clear if angina is not a prominent symptom.
Show notes - Aortic Stenosis and the Story of TAVR
(TAVR/TAVI are using interchangeably)
CardioNerds Aortic Stenosis, updated 1.20.21
1. In the 1990s, patients with severe aortic stenosis (AS) who were deemed to be at high surgical risk would weigh the risks of surgery and prolonged recovery. Balloon Aortic Valvuloplasty (BAV) was first performed by Dr. Alain Cribier in 1986. The technique was based on the foundation of pulmonary valvuloplasty performed initially in 1982 by Drs. Jean Kan and Bob White, and mitral valvuloplasty in 1984. BAV was initially touted as an efficacious cure for aortic stenosis, but unfortunately it had a high restenosis rate as well as high risks for stroke and vascular complications (no closure devices at that time) with an overall poor long-term prognosis. Balloon aortic valvuloplasty was primarily used for decompensated Class IV heart failure in non-surgical candidates.
2. Transcatheter aortic valve replacement (TAVR/TAVI) was developed and first performed in human in 2002.(1) This was performed by Dr. Alain Cribier in France in 2002, initially by trans-septal approach and then by retroaortic approach. Here is a representative diagram of the procedure.
Figure: Transcatheter Aortic-Valve Replacement. The transcatheter valve is positioned at the level of the native aortic valve during the final step of valve replacement, when the balloon is inflated within the native valve during a brief period of rapid ven...
180. Narratives in Cardiology: Raising Women Leaders in Academic Cardiology with Dr. Anu Lala
Feb 17, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Leticia Helms (Internal medicine resident at Columbia University), Dr. Silia DeFilippis (AHFT FIT at Columbia University), and Dr. Anu Lala (AHFT faculty and program director at Mount Sinai Hospital) to discuss diversity and inclusion in academic cardiology and more in this installment of the Narratives in Cardiology Series. The President of the New York ACC Chapter Dr. Hima Vidula discusses D&I initiatives at her chapter. Episode introduction and audio editing by CardioNerds Academy Intern, Shivani Reddy.
Although women compose 50% of medical students in the United States, cardiology remains a male dominated field. Gender disparity is even more prominent when we look at leadership positions. In this episode we discuss why and how cardiology (and advanced heart failure) can be such a rewarding field for women. The episode reflects on the significant contributions women have made to the field in the past and how they continue to move the field with respect to clinical care and research.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • Production Team
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Tweetorial - Raising Women Leaders in Academic Cardiology with Dr. Anu Lala
https://twitter.com/Gurleen_Kaur96/status/1509286469051031556?s=20&t=9BFDUXbSnWLcAc5-daXK2A
Video version - Raising Women Leaders in Academic Cardiology with Dr. Anu Lala
https://youtu.be/vVuhUCbqwYk
Quotables - Raising Women Leaders in Academic Cardiology with Dr. Anu Lala
“We all have multiple roles – and those roles don’t always have to be completely distinct and separate from one another. You know, our ability in one role, maybe it makes us better at another.”“I felt like being there was like in medical Disneyland for research.” - Anu Lala“Heart failure is unique in that it truly requires that cross disciplinary collaboration at the precipice of what is often life and death.” - Anu Lala“It points to the importance of seeing people do things before you who look like you.” - Anu Lala“All human beings want to feel heard. They want to feel seen and they want to feel like their voice matters.” - Anu Lala“consciously deliberately disruptive”“I like the idea of calling it work-life harmony.”
Show notes - Raising Women Leaders in Academic Cardiology with Dr. Anu Lala
How do women compare to men in cardiology in 2022?Although nearly 50% of US medical graduates and more than 40% of internal medicine graduates are women, the field of cardiology remains male dominated.Approximately 20% of general cardiology fellows are women, which is comparable to women in surgical subspecialties like neurosurgery (17%), thoracic surgery (21%), and orthopedic surgery (15%) (Reza 2021).Additionally, women hold significantly fewer leadership positions and are less likely to be promoted to senior academic ranks.Out of LBCT presented at ACC 2021, zero had a female first author and zero were presented by women (Kaur 2021).What may make heart failure unique with respect to the recruitment of ...
179. Lipids: Polyunsaturated Fatty Acids, Omega-3 Fatty Acids, Eicosapentaenoic acid – Mechanisms of Action with Dr. Ty Gluckman
Feb 16, 2022
CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic), Rick Ferraro (Director of CardioNerds Journal Club and cardiology fellow at the Johns Hopkins Hospital), and CardioNerds Healy Honor Roll Ambassador Dr. Justice Oranefo (UConn cardiology fellow) discuss omega-3 fatty acids acid with Dr. Ty Gluckman, preventive cardiologist and medical director of the Center for Cardiovascular Analytics, Research, and Data Science (CARDS) at the Providence St. Joseph Heart Institute in Portland, Oregon. Audio editing by CardioNerds Academy Intern, Christian Faaborg-Andersen.
In the recent years, purified omega 3 fatty acids and its esters have emerged as a potential new tool in our arsenal for management of hypertriglyceridemia and atherosclerotic coronary artery disease. In this episode we review the sources and basic structure of these compounds, as well as their metabolic effects as it pertains to cardiovascular disease. Using hypothetical patient cases, we also discuss scenarios in which these therapies can be useful.
This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Relevant disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls
Omega 3 (n-3) fatty acids are a class of polyunsaturated fatty acids [PUFA]. The most studied n-3 fatty acids include eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA] and alpha linoleic acid [ALA]. ALA is found in certain vegetable oils while EPA and DHA are abundant in fish sources.Cardiovascular benefits of n-3 fatty acids include blood pressure reduction, enhanced diastolic function, triglyceride reduction, and immunomodulatory properties.Inflammation plays a major role in the atherogenic process and plaque rupture. Inflammatory marker hs-CRP is a risk enhancing factor for predicting future ASCVD risk. Ongoing trials are investigating therapy that target the inflammatory process in treatment of atherosclerotic heart disease.Prevention and management of ASCVD require aggressive lifestyle modifications and medical therapy addressing risk factors and underlying inflammatory conditions.Purified forms of n-3 fatty acids are approved for the treatment of severe hypertriglyceridemia and as an adjunct therapy to statins for reduction of coronary events in high-risk individuals.
Show notes
1. What are omega 3 (n-3) fatty acids? What are the natural sources of n-3 fatty acids?
n-3 fatty acids are class of polyunsaturated fatty acids [PUFA]. PUFA are types of unsaturated fats that have more than one double bond in their backbone. PUFAs are important constituents of the phospholipids of all cell membranes.The most studied n-3 fatty acids include eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA] and alpha linoleic acid [ALA].ALA is found in certain vegetable oils including walnuts, flaxseeds, chia seeds. EPA and DHA are abundant in cold water fish oils such as salmon, mackerel, tuna sardines. Interestingly, farm raised fish usually have higher levels of EPA and DHA than wild caught fish; however, this depends on what the fish are fed. Another important class of PUFAs are omega 6 (n-6) fatty acids, found in vegetable oils (1,2).
2. What are the metabolic effects of omega 3 fatty acids?
Multiple early studies have demonstrated the anti-inflammatory properties of n-3 fatty acids.The typical Western diet with a high arachidonic acid (an n-6 fatty acid) content promotes atherogenesis leading to the high incidence of CAD in this population.
178. Case Report: Occam’s Razor or Hickam’s Dictum? Cardiogenic Shock With Severe Biventricular Heart Failure – Northwestern University
Feb 10, 2022
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Loie Farina (Northwestern University CardioNerds Ambassador), Dr. Josh Cheema, and Dr. Graham Peigh from Northwestern University for drinks along the shores of Lake Michigan at North Avenue Beach. They discuss a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presents with progressive symptoms of heart failure and is found to have a severe, non-ischemic cardiomyopathy. The etiology of her cardiomyopathy is not clear until her untimely death. She is ultimately diagnosed with cardiac AL amyloidosis with isolated vascular involvement a real occam’s razor or hickam’s dictum conundrum. We discuss the work-up and management of her condition including a detailed discussion of the differential diagnosis, the underlying features of systemic sclerosis with cardiac involvement as well as cardiac amyloidosis, the role of a shock team in managing cardiogenic shock, and how to identify those with advanced or stage D heart failure. Advanced heart failure expert Dr. Yasmin Raza (Northwestern University) provides the ECPR segment. Episode introduction by CardioNerds Clinical Trialist Dr. Liane Arcinas. Audio editing by CardioNerds Academy Intern, Christian Faaborg-Andersen.
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Case Summary - Occam’s Razor or Hickam’s Dictum?
This is a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presented with progressive dyspnea on exertion and weight loss over the course of 1 year. Her initial work-up was notable for abnormal PFTs and finding of interstitial pneumonia on high-resolution CT, an ECG with frequent PVCs and normal voltage, a transthoracic echocardiogram with a mildly reduced ejection fraction of 40%, and a right/left heart catheterization with normal coronary arteries, filling pressures, and cardiac output. Scleroderma-related cardiac involvement is suspected. She is placed on GDMT, but her condition worsens over the next several months, and repeat echocardiogram shows severely reduced biventricular function, reduced LV global longitudinal strain (GLS) with apical preservation of strain, severely reduced mitral annular tissue Doppler velocities, and a normal left ventricular wall thickness. Scleroderma-related cardiac involvement remains highest on the differential, but because of some findings on the echo that are concerning for cardiac amyloidosis, an endomyocardial biopsy was obtained. It showed vascular amyloid deposition without interstitial involvement. The diagnosis of cardiac amyloid was discussed but deemed unlikely due to lack of interstitial involvement. However, a serologic work-up soon revealed a monoclonal serum lambda light chain and a follow-up bone marrow biopsy showed 20% plasma cells. She was discharged with very near-term follow-up in oncology clinic with a presumptive diagnosis of AL amyloidosis, but she unfortunately returned in shock and suffered a cardiac arrest. She initially survived and underwent emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation with subsequent left ventricular assist device placement (LVAD). However, she passed away due to post-operative hemorrhage. Autopsy was consistent with a final diagnosis of cardiac AL amyloidosis with isolated vascular involvement.
Case Media - Occam’s Razor or Hickam’s Dictum?
EKG
CXR
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Episode Teaching -Occam’s Razor or Hickam’s Dictum?
Pearls
Scleroderma causes repeated focal ischemia-reperfusion injuries which result in patchy myocardial fibrosis. Cardiac involvement in scleroderma is frequent but often not clinicall...
177. CCC: Cardiac Arrest, E-CPR, & Post-Arrest Care with Dr. Jason Bartos
Feb 07, 2022
Approximately 350,000 adults per year in the US experienced out-of-hospital cardiac arrest (OHCA). Only about 10% of such patients survive their initial hospitalization. The key drivers of successful resuscitation from OHCA are bystander cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Survival rates from OHCA vary dramatically between US regions. For instance, the extracorporeal CPR (eCPR) program at the University of Minnesota has over a 40% survival rate in patients with OHCA and refractory ventricular fibrillation (VF) based on data published in the ARREST trial. In this episode, we are joined by experts from the University of Minnesota, including Dr. Jason Bartos (Interventional and Critical Care Faculty) and Dr. Julie Power (Chief Fellow at University of Minnesota and CardioNerds Academy Fellow), along with Dr. Yoav Karpenshif (Co-Chair Critical Care Series, University of Pennsylvania) and CardioNerds Co-Founders (Amit Goyal and Dan Ambinder) to discuss cardiac arrest, E-CPR, & post-arrest care. This includes targeted temperature management, coronary angiography and revascularization, as well as the growing field of eCPR and VA ECMO. Episode introduction by CardioNerds Clinical Trialist Dr. Jason Feinman. Audio editing by CardioNerds Academy Intern, Shivani Reddy.
The CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Mark Belkin, Dr. Eunice Dugan, Dr. Karan Desai, and Dr. Yoav Karpenshif.
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Abbreviations - Cardiac Arrest, E-CPR, & Post-Arrest Care
eCPR- extracorporeal cardiopulmonary resuscitation
VA ECMO- veno-arterial extracorporeal membrane oxygenation
VT/VF- ventricular tachycardia/ventricular fibrillation
ACLS- advanced cardiovascular life support
ROSC- return of spontaneous circulation-
OHCA- out-of-hospital cardiac arrest
IHCA- in-hospital cardiac arrest
TTM- targeted temperature management
Pearls and Quotes - Cardiac Arrest, E-CPR, & Post-Arrest Care
The ARREST trial showed early VA ECMO-facilitated resuscitation for patients with OHCA and refractory VF significantly improved survival to hospital discharge when compared to standard ACLS treatment.Coronary artery disease is common in the setting of cardiac arrest, with up to 96% of patients with STEMI on post resuscitation EKG and up to 85% of refractory out-of-hospital VT/VF arrests.Guidelines recommend emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG.The role of timing of revascularization after ROSC in patients without STEMI or shock is unknown.The role of coronary angiography in cardiac arrest with nonshockable rhythms is also unclear.The current AHA guidelines recommend initiation of targeted temperature management between 32°C and 36°C for at least 24 hours for all patients who do not follow commands after ROSC in both OHCA and IHCA.
Show notes - Cardiac Arrest, E-CPR, & Post-Arrest Care
1. What are early post arrest management considerations?
The key drivers of successful resuscitations from OHCA: CPR and public use of AEDs in the field. After initial stabilization, care of the critically ill post-arrest patient hinges on hemodynamic support, mechanical ventilation, temperature management, attending to adverse sequelae of arrest, and diagnosis and treatment of underlying causes of arrest. Coronary artery disease is common in the setting of VT/VF cardiac arrest,
176. Narratives in Cardiology: Interventional Cardiology, Cardioobstetrics, & Work Life Integration with Dr. Ki Park – Florida Chapter
Feb 04, 2022
CardioNerd (Amit Goyal), Dr. Zarina Sharalaya (Interventional cardiology fellow at the Cleveland Clinic), Dr. Ashley Mohadjer (Interventional cardiology fellow, Vanderbuilt Heart and Vascular Institute), and Dr. Laurie Mbuntum (Cardiology fellow, UTSW) join Dr. Ki Park (Associate professor of medicine and an interventional cardiologist at the University of Florida and Malcom Randall VA Medical Center in Gainesville, FL.) for a a well-rounded discussion on all things ‘Women-in-Cardiology' #WIC . Dr. Ki Park discusses how she nurtured her interest in interventional cardiology, and further shares her thoughts and passion for cardio-obsetrics. She shares her advice for trainees thinking about interventional or cardioobetrics and anecdotes from her training as a successful woman in the field. We discuss the need for education on pregnancy outcomes and long-term cardiovascular risk, ideas to lower maternal mortality, how to start a women’s cardiovascular clinic, and her thoughts on how the field may look in the future. Special message by Florida ACC State Chapter Governor, Dr. David Perloff. Episode introduction and audio editing by CardioNerds Academy Intern, Shivani Reddy.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • Production Team
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Video version - Interventional Cardiology, Cardioobstetrics, & Work Life Integration with Dr. Ki Park
https://youtu.be/_oYUc-_sdfU
Tweetorial - Interventional Cardiology, Cardioobstetrics, & Work Life Integration with Dr. Ki Park
https://twitter.com/gurleen_kaur96/status/1495921275545563136?s=21
Quotables - Interventional Cardiology, Cardioobstetrics, & Work Life Integration with Dr. Ki Park
“I like the work life integration as opposed to work life balance. Balance just implies that you always have everything aligned perfectly at all times and that is just not doable.”Dr. Ki Park
Show notes - Interventional Cardiology, Cardioobstetrics, & Work Life Integration with Dr. Ki Park
Why is screening for OB-GYN history for cardiovascular risk is important, and who should be responsible?
Pregnancy is nature’s stress test and in some women can unmask someone’s predisposition to cardiac diseaseYearly screening for diabetes, hypertension, dyslipidemiaBig interdisciplinary effort in attempt to try to capture all women at risk, as many will not present with manifestation of disease initially
How did you nurture your interest in cardioobsetrics? In interventional cardiology?
Meetings and societiesConnect with those who work in the field, social mediaRegarding interventional cardiology – having interest in procedures, do as many cases “hands on” as possible, learning from mistakes
What advise do you have to achieve work and life balance?
It's important to understand the various occupational hazards of radiation exposure which include but are not limited to brain tumors, cataracts, thyroid disease, cardiovascular diseases, musculosketal problems and reproductive side effects.
Have grace,
175. ACHD: Single Ventricle Circulation and Fontan Palliation with Dr. Yuli Kim
Jan 27, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chair Dr. Daniel Clark (Vanderbilt University), and ACHD FIT lead Dr. Danielle Massarella (Toronto University Health Network) join ACHD expert Dr. Yuli Kim (Associated Professor of Medicine & Pediatrics at the University of Pennsylvania), to discuss single ventricular heart disease and Fontan palliation. They cover the varied anatomical conditions that can require 3-step surgical palliation culminating in the Fontan circulation, which is characterized by passive pulmonary blood flow, high venous pressures, and low cardiac output. Audio editing by Dr. Gurleen Kaur (Director of the CardioNerds Internship and CardioNerds Academy Fellow).
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
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Pearls • Notes • References • Guest Profiles • Production Team
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Pearls
There are various forms of unpalliated ‘single ventricle’ congenital heart disease. The three main hemodynamic issues that need to be addressed in any form are unbalanced flow, pulmonary over-circulation, and blood mixing.
The Fontan palliation is a series of operations for congenital heart disease patients in whom biventricular repair is not feasible.
In the completed Fontan circulation, systemic venous blood is surgically routed directly to the lungs, effectively bypassing the heart, and creating passive pulmonary blood flow.
The hallmarks of the Fontan circulation (and Fontan failure) are elevated central venous pressure and low cardiac output.
Patients with Fontan circulation may experience significant morbidity in the long term from both cardiac and non-cardiac sequelae, and require lifelong specialist care.
Show notes
1. Why do some patients require Fontan palliation?
Many different types of anatomies may ultimately require single ventricular palliation via the Fontan procedure due to inadequate biventricular function to support both pulmonary and systemic circulations. Some examples include Tricuspid Atresia (hypoplastic RV), Double Inlet Left Ventricle (DILV; hypoplastic RV), Hypoplastic Left Heart Syndrome (HLHS; hypoplastic LV), and atrioventricular septal defects (AVSD; either RV or LV may be inadequate based on “commitment” of the common AV valve). The Fontan procedure was first described in 1971; at this time, mortality of single ventricular patients exceeded 90% in the first year of life.
2. What are the stages of Fontan palliation?
Effective pulmonary blood flow/balancing flow to the pulmonary and systemic circulations: for many conditions, this involves retrograde pulmonary blood flow from a systemic -> PA shunt (i.e. Blalock-Taussig-Thomas “BTT” shunt in which the subclavian artery is turned down and anastomosed to the pulmonary artery). In infants, the pulmonary vascular resistance (PVR) is high perinatally and gradually lowers over the first 3 months of life to adult levels with exposure to the atmosphere’s natural pulmonary vasodilator: oxygen. Thus, in the first 3 months of life babies have an intri...
174. Cardio-Obstetrics: Black Maternal Health with Dr. Rachel Bond
Jan 21, 2022
CardioNerds (Amit Goyal), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), fellow lead Dr. Victoria Thomas (Cardionerds Ambassador, Vanderbilt University Medical Center), join Dr. Rachel Bond (Women's Heart Health Systems Director at Dignity Health, Arizona) for a cardio-obstetrics discussion about Black maternal health. Episode introduction by CardioNerds Clinical Trialist Dr. Chistabel Nyange. Audio editing by CardioNerds Academy Intern, Christian Faaborg-Andersen.
This episode was developed in collaboration with the Association of Black Cardiologists. ABC is a 501(c)3 nonprofit organization whose mission is to promote the prevention and treatment of cardiovascular disease, including stroke, in Black persons and other minority populations, and to achieve health equity for all through the elimination of disparities. Learn more at https://abcardio.org/.
Notes • References • Guest Profiles • Production Team
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Show notes
1. Why does Black Maternal Health need to be deliberately highlighted episode on CardioNerds?
Black women are three-four times more likely to die during their pregnancy. The deaths are primarily tied to cardiomyopathy and cardiovascular conditions such as coronary artery disease, pulmonary hypertension, chronic hypertension, preeclampsia, and eclampsia.63-68% of this cardiovascular mortality is preventable depending on one’s racial identity. As CardioNerds, we must educate ourselves on why this occurs and identifying diseases that may place patients at increased risk.Studies have shown the Black maternal mortality crisis exist irrespective of one’s education or socioeconomic status.We must recognize and admit that some patients are being treated differently because of their race and ethnicity alone.
2. When we consider or acknowledge a patient’s race, what should CardioNerds think about?
Race is an important factor to think about, but we must remember that it is an imperfect variable. We should not focus on biology or genetic make-up. We should think about social determinants of health. 60% of the time social and personal aspects dictate one’s health.Unconscious biases and structural racism are likely playing a major role in race-based health inequities.
3. What are other vulnerable groups that have increased mortality rates related to cardioobstetric care?
Native American women have similar maternal mortality rates to Black populations.Women who are veterans, live in rural communities, and/or are currently incarcerated have increased risk of mortality
4. What are some of the social determinants of health that should be considered for these patients?
Food deserts or having poor access to nutrient rich/quality foods make these vulnerable patients have increased risk factors for high cholesterol, high blood pressure, obesity, and diabetes which increase the risk for pregnancy complications and infertility.The above vulnerable populations can have less access to higher levels of care for high-risk pregnancies.
5. What are some of the preventable causes of maternal mortality?
Clinicians should actively listen to their patients' concerns. There have been several media stories in the news and on CardioNerds episodes where women’s concerns were not acknowledged or taken seriously.Preconception counseling is important to provide to all patients. 50% of women have one risk factor for cardiovascular disease when entering pregnancy. We should have discussions with patients regarding their lifestyles, with an emphasis on exercise and diet.
6. What are some of the psychosocial or health related differences we see in black mothers when compared to other...
173. Case Report: A Block and a Leak Lead to Shock – Weill Cornell
Jan 17, 2022
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Jaya Kanduri, Dr. Dan Lu, and Dr. Joe Wang from Weill Cornell Cardiology for Levain cookies in Central Park. The ECPR is provided by Dr. Harsimran Singh (Cardiology Program Director and Interventional Cardiologist with expertise in ACHD). Episode introduction by CardioNerds Clinical Trialist Dr. Jeremy Brooksbank.
We discuss a case of a 24-year-old female with a history of unicuspid aortic valve with associated aortopathy status post mechanical aortic valve replacement and Bentall procedure at age 16 presents with acute onset substernal chest pain and shortness of breath. She was found to have mechanical aortic valve obstruction and severe aortic regurgitation resulting in cardiogenic shock. Unfortunately, the shock quickly progressed to refractory cardiac arrest requiring mechanical support with VA-ECMO before valve debridement was performed in the operating room. The differential for mechanical prosthetic valve stenosis includes pannus, thrombus, or vegetation. She was eventually found to have thrombus obstructing the outflow tract and holding the mechanical leaflets open leading to torrential regurgitation. She underwent successful surgical debridement. We discuss unicuspid aortic valve and associated aortopathy, surgical considerations regarding AVR, diagnosis and management of prosthetic valve dysfunction, approach to cardiogenic shock and considerations around activating and managing VA-ECMO.
With this episode, the CardioNerds family warmly welcomes Weill Cornell Cardiology to the CardioNerds Healy Honor Roll. The CardioNerds Healy Honor Roll programs support and foster the the CardioNerds spirit and mission of democratizing cardiovascular education. Healy Honor Roll programs nominate fellows from their program who are highly motivated and are passionate about medical education. The Weill Cornell fellowship program director, Dr. Harsimran Singh has nominated Dr. Jaya Kanduri for this position.
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Disclosures: NoneJump to: Pearls - Notes - References
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Case Media
ECGCXREchoRHC
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LHC - LCA
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Episode Teaching
Pearls - Mechanical Valve Thrombosis
(1) Unicuspid aortic valves present with aortic stenosis earlier in life. There can be concurrent aortic regurgitation and, like bicuspid aortic valves, unicuspids can be associated with aortopathy as well as other congenital anomalies.
(2) Prosthetic valve stenosis is assessed with different echocardiographic parameters than what we use for native valves. The differential for mechanical valve stenosis includes pannus, thrombus, or vegetation. Patient prosthesis mismatch may also lead to elevated gradients.
(3) VA-ECMO provides robust flow in the setting of cardiogenic shock as well as gas exchange. While this flow may improve end-organ perfusion, it also increases left ventricular afterload, thereby potentially worsening LV ischemia and impeding LV recovery. Elevated afterload may also decrease innate contractility and prevent aortic valve leaflets from opening. Therefore, if a patient with a mechanical valve is on VA-ECMO, ensuring valve opening to prevent valve (or ventricular) thrombosis is paramount.
(4) Venting is sometimes necessary to decrease the left ventricular end diastolic pressure from the high afterload imposed by VA-ECMO. A microaxial temporary LVAD (example – Impella device) directly unloads the left ventricle, but cannot be used in the setting of a mechanical aortic valve. TandemHeart is also a consideration (inflow cannula placed across the interatrial septum in the left atrium) to unload the LV,
172. CCC: The Hemodynamic Evaluation of Cardiogenic Shock with Dr. Nosheen Reza
Jan 11, 2022
The hemodynamic evaluation of cardiogenic shock obtained via a Swan-Ganz catheter plays an essential role in the characterization of cardiogenic shock patients. Join Dr. Nosheen Reza, (Assistant Professor of Medicine and Advanced Heart Failure and Transplant cardiologist at the Hospital of the University of Pennsylvania), episode fellow lead Dr. Brian McCauley (Interventional and Critical Care Fellow at the Hospital of the University of Pennsylvania), Dr. Mark Belkin (Cardiac Critical Care Series Co-Chair and AHFT fellow at University of Chicago), and CardioNerds Co-Founders, Amit Goyal and Dan Ambinder, for this tour through the heart aboard the Swan-Ganz catheter. In this episode, we evaluate three separate admissions for a single patient to highlight pearls regarding waveform assessment, evaluating cardiac output, phenotyping hemodynamic profiles, targeted therapies based on hemodynamics and so much more. Episode introduction and audio editing by Dr. Gurleen Kaur (Director of the CardioNerds Internship).
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Pearls and Quotes - Hemodynamic Evaluation of Cardiogenic Shock
Swan-Ganz catheters are not dead #ReviveTheSwan! They remain a useful tool to characterize cardiac patients & to help direct therapy, especially in Cardiogenic Shock.When looking at Swan-Ganz catheter data, it is important to always interpret your own tracings, to know what values are acquired directly, and which values are derived.It is important to understand the strengths and weakness of hemodynamic characterization by Swan-Ganz cathetersAdvanced metrics such as cardiac power output, pulmonary artery pulsatility index, and aortic pulsatility index are extremely useful in further phenotyping patients as well as guiding mechanical support platforms“The data will be wrong if the preparation is not right”
Show notes - Hemodynamic Evaluation of Cardiogenic Shock
1. Swan-Ganz catheters are a useful tool to characterize cardiac patients and to direct therapy.
With the ESCAPE trial in 2004, Swan-Ganz catheter utilization dropped drastically outside transplant centers across the United States (2). While the ESCAPE trial did demonstrate the possibility of harm when using a Swan-Ganz catheter, many of the truly ill cardiac patients we care for would have been excluded from the trial. For instance, patients on dobutamine at doses above 3 µg/kg/min or any dose of milrinone during the hospitalization were excluded from the trial.This is a classic example of “throwing the baby out with the bath water.”In a recent large, multicenter cardiogenic shock registry, complete hemodynamic assessment using pulmonary artery catheters prior to MCS is associated with lower in-hospital mortality compared with incomplete or no assessment (3).
2. When looking at Swan-Ganz catheter data, it is important to always interpret your own tracings, to know what values are acquired directly, and which values are derived.
Incomplete or incorrect data can lead to mischaracterization of our patients. Therefore, it is essential to review all of the tracings, calculations, and data acquired for each individual patient before any clinical adjustments are made (1). An incomplete pulmonary capillary wedge tracing is an example from clinical practice (causing the PCWP, and therefore the left-sided filling pressures to be overestimated). It is equally important to know the limitations of cardiac output equations, and that no one measurement is perfect.Foibles of the Fick equation include assumed rather than measured oxygen consumption and variations in hemoglobin concentration. Traditionally,
171. Narratives in Cardiology: Innovation, Excellence and Leadership in Interventional Cardiology with Dr. Samir Kapadia – Ohio Chapter
Jan 07, 2022
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Zarina Sharalaya (Interventional Cardiology Fellow at the Cleveland Clinic), and Dr. Simrat Kaur (General Cardiology Fellow at the Cleveland Clinic) join Dr. Samir Kapadia, the Chair of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. They discuss future advancements in the field of structural interventional cardiology. Dr. Kapadia sheds light on his journey starting as an international medical graduate from India and speaks about his mentors that helped shape his career and his life. We later delve into several advancements in the field of structural and interventional cardiology, along with the amalgamation of different sub-specialities with intervention such as heart failure and critical care cardiology. We also discuss the measures being taken to reduce the occupational hazards associated with interventional cardiology and how to make this field more appealing to women in cardiology. Special message by Ohio ACC State Chapter Governor, Dr. Kanny Grewal.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • References • Production Team
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Tweetorial on Innovation, Excellence and Leadership in Interventional Cardiology with by Dr. Gurleen Kaur
https://twitter.com/gurleen_kaur96/status/1484205728663576590?s=21
Video version - Innovation, Excellence and Leadership in Interventional Cardiology with Dr. Samir Kapadia
https://youtu.be/BfqnRkaVGkk
Quotables - Innovation, Excellence and Leadership in Interventional Cardiology with Dr. Samir Kapadia
“A very important thing for all international medical graduates and for everybody, for that matter - it is important to recognize that the opportunities are what you perceive and not what others perceive.”Dr. Samir Kapadia
Show notes - Innovation, Excellence and Leadership in Interventional Cardiology with Dr. Samir Kapadia
How do international medical graduates contribute to the work force in medicine across the United States of America?
International medical graduates account for 25% of the physician work force, with over 85% being involved in direct patient care.IMGs are usually accomplished, consummate and highly motivated physicians who often have to overcome challenges such as language proficiency, acculturation and difficulties with obtaining a visa status in the United States.IMGs also help fill gaps in health care by working in geographical areas that are otherwise not desirable by US or Canadian medical graduates.IMGs contribute to diversity of the field which provides a richer training environment, improved access to health care for underrepresented minorities, as well as better patient outcomes.
What are key qualities of a good mentor?
A good mentor is responsible for enhancing the education of his or her mentees along with motivating them to challenge their limits.Qualities of a good mentor extend beyond mere mentorship to s...
170. ACHD: Transposition of the Great Arteries with Dr. Maan Jokhadar
Jan 03, 2022
In this episode, CardioNerds (Amit Goyal), ACHD series co-chair, Dr. Josh Saef (ACHD fellow at University of Pennsylvania) and episode lead fellow, Dr. Brynn Connor (Pediatric Cardiology fellow at Lucile Packard Children's Hospital at Stanford) are joined by Dr. Maan Jokhadar (Advanced heart failure and adult congenital heart disease specialist at Emory University) to discuss transposition of the great arteries. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
For a brief review of the basic anatomy and physiology of D-TGA, check-out this great video by Dr. Maan Jokhadar!
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
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https://www.youtube.com/watch?v=Ifu8nVtXT_c
Pearls
(1) In D-TGA following an atrial switch operation, the right ventricle IS the systemic ventricle!
(2) Evaluation of systemic right ventricular function often requires use of both transthoracic echocardiography and cardiac MRI.
(3) Use of medical heart failure therapies should be individualized, without any proven long-term mortality benefit and potential unique complications in this patient population (i.e. SA node dysfunction).
Show notes
D-transposition of the great arteries (D-TGA) is one of the most common forms of cyanotic congenital heart disease presenting in the newborn period. Anatomically, d-transposition of the great arteries is characterized by atrioventricular concordance and ventriculoarterial discordance, such that the aorta arises from the morphologic right ventricle and pulmonary artery arises from the morphologic left ventricle. The resultant physiology is that of a parallel circulation, with deoxygenated blood recirculating in the systemic circulation (via the RA-RV) and oxygenated blood recirculating in the pulmonary circulation (via the LA-LV). At birth, this invariably results in cyanosis, with survival dependent upon adequate mixing of the two circulations via an atrial or ventricular level defect.
Prior to surgical advances in the late 1950s, this lesion was uniformly fatal, with most infants dying before their first birthday. The subsequent development of the Senning and Mustard atrial-level repairs led to good immediate outcomes and improved long-term survival. However, following these “physiologic” types of repair, patients are far from cured, with several long-term established complications, including (1) dysfunction of the systemic right ventricle, (2) tricuspid regurgitation (the systemic atrioventricular valve), (3) atrial and ventricular arrhythmias, and (4) systemic and pulmonary venous baffles leaks and obstruction. These complications ultimately lead to substantial morbidity and premature mortality, with ACHD providers facing unique challenges in the medical and surgical management of this heterogenous patient population.
1. What are the basic anatomic features of d-transposition of the great arteries (d-TGA)?
169. Case Report: Chest pain in a Young Man – “A Gray (Gy) Area” – UC San Diego
Dec 26, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Patrick Azcarate and Dr. Antoinette Birs from the University of California San Diego along with a guest host Dr. Christine Shen from Scripps Health for a hike along Torrey Pines. They discuss a case of a 30-year-old man with a history of malignant thymoma status post two partial lung resections and radiation for pleural/pulmonary metastasis, as well as a history of myasthenia gravis on rituximab, and Ig deficiency on IVIG presents with progressive exertional chest pain. We focus on the differential diagnosis of patients with a history of chest radiation exposure and dive into the complex management and surveillance for patients with radiation associated cardiac disease (RACD). The E-CPR is provided by Dr. Milind Desai (multimodality cardiovascular imaging expert, Director of Clinical Operations, Director of Center for HCM, Medical Director for Center for Aortic Diseases, and Medical Director for Center for Radiation Heart Disease at the Cleveland Clinic).
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Disclosures: NoneJump to: Pearls - Notes - References
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Case Media
TTE
TTE
TTE
TTE
AP Cranial Pre PCI
LAO Caudal Pre PCI
RAO Caudal Pre PCI
RAO Cranial Pre PCI
AP cranial Post PCI
Episode Teaching
Pearls - radiation associated cardiac disease
Radiation-associated cardiac disease (RACD) is a heterogeneous disease that can manifest several years, or decades following radiation exposure to the chest and is associated with high morbidity and mortality. Given the non-specific or vague symptoms, one of the greatest challenges for this patient population may be diagnosing RACD which requires high clinical suspicion. In patients with a history of chest radiation, we should remember to ask three important questions: 1. What was the total dose of radiation given? 2. How long ago was radiation therapy administered? 3. Was the heart exposed?A cumulative dose of >30 Gray (Gy) chest radiation significantly increases the risk of RACD long-term, but cardiac damage can occur at even lower doses. Effects from chest radiation can take years to become clinically detectable. Screening for radiation induced coronary artery disease with stress testing should start 5 years following XRT and in low-risk patients (without risk factors for typical coronary artery disease) and continue at 5-year intervals, and 2-year intervals in high-risk patients. Valvular heart disease surveillance should begin 10 years post XRT and can be accomplished with echocardiogram. Regarding revascularization planning, a Heart Team approach is recommended. However, percutaneous intervention is preferred over bypass surgery in most cases.
Notes - radiation associated cardiac disease
1. What is Radiation-Associated Cardiac disease (RACD)?
A spectrum of disease that can affect any part of the heart and typically develops anywhere from 5 to 20 years after radiation. It may present with non-specific or vague symptoms. Manifestations include myocarditis, pericarditis (typically early in the course) and well as long term sequela such as myocardial fibrosis, valvular heart disease (regurgitation or stenosis), pericardial disease, vasculopathy (CAD), conduction system disease. Radiation may impact any tissue of the heart:
Vascular: microvascular, coronary artery disease, macrovascular (ascending aorta)
Valvular: has a longer latency ~10-20 years with the left sided valves being more commonly affected; Aorto-mitral curtain thickening/calcification is a hallmark of previous heart radiation and associated with higher mortality
Conduction: Sick sinus syndrome, AV nodal block,
168. CCC: Cardiogenic Shock – Initial Assessment and The Shock Team Call with Dr. Anu Lala
Dec 21, 2021
Cardiogenic shock is a state of cardiac dysfunction leading to hemodynamic instability and end-organ hypoperfusion. At the bedside, clinicians take various data points – from history to physical exam to labs/imaging and invasive hemodynamics – to make an assessment of the etiology, severity and management of cardiogenic shock. Health systems have developed “Shock Teams” to collectively interpret this data to deliver the optimal care for each patient. In this episode, Dr. Mark Dela Cruz (Advanced Heart Failure and Transplant Fellow at University of Chicago), CardioNerds Critical Care Series Co-Chairs Dr. Mark Belkin (Advanced Heart Failure and Transplant Fellow at University of Chicago) and Dr. Karan Desai (General Cardiology Fellow at University of Maryland), and CardioNerds Co-Founder Dr. Daniel Ambinder (Structural Fellow at Johns Hopkins Hospital) join Dr. Anu Lala (Director of the AHFT Fellowship, Associate Professor of Medicine and Cardiology at Mount Sinai Hospital and Deputy Editor of the Journal of Cardiac Failure) on a Shock Team Call! Dr. Lala leads us in a discussion of the systematic bedside evaluation of cardiogenic shock, from understanding a patient’s physiology and their humanity, to manage their illness and make a rapid but thorough evaluation when on the Shock Call. Audio editing and episode introduction by CardioNerds Academy Intern, Hirsh Elhence.
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Pearls and Quotes - Shock Team Call
The classic definition of cardiogenic shock was derived from studies of left ventricular dysfunction in the setting of acute myocardial infarction. With the advent of early primary percutaneous coronary intervention (PCI) and trends in cardiovascular disease risk factors, the prevalence of non-ischemic etiologies of cardiogenic shock (e.g., progression/exacerbation of chronic heart failure) has increased significantly.
The diagnosis of cardiogenic shock should be made by integrating key clinical features such as physical exam findings and objective laboratory and imaging data in an iterative fashion. Focused transthoracic echocardiography and invasive hemodynamics are helpful in further characterizing the type of shock and the etiology of cardiogenic shock.
Early evaluation of right ventricular function is an important aspect of cardiogenic shock evaluation. Significant RV dysfunction portends poor prognosis, can necessitate more aggressive interventions, and defines the types of mechanical circulatory support necessary.
Classification systems for cardiogenic shock help to further characterize a patient’s illness severity. The INTERMACS and SCAI classification systems are particularly designed to allow for early identification of patients who would most benefit from more advanced interventions such as vasoactive medications or mechanical circulatory support.
Shock Team Calls improve mortality for patients in cardiogenic shock. By rapidly bringing together heart failure specialists, interventional cardiologists, cardiothoracic surgeons, and critical care physicians, appropriate interventions and contingencies can be discussed and quickly implemented without adding delays to patient care. Importantly, these calls should attempt to integrate patient goals of care in order to best serve our patients.
Show notes - Shock Team Call
1. What is the classic definition of cardiogenic shock?
The classic definition of cardiogenic shock was initially derived from the Shock Trial published in 1999 (1). In this trial, cardiogenic shock was defined as shock due to left ventricular dysfunction occurring in the setting of acute myocardial infar...
167. Cardio-Obstetrics: Cardiac Interventions During Pregnancy with Dr. Michael Luna
Dec 16, 2021
In this episode, CardioNerds (Amit Goyal), Cardio-OB series co-chair and UT Southwestern cardiology fellow, Dr. Sonia Shah, and episode lead fellow, Dr. Laurie Femnou (UT Southwestern) are joined by Dr. Michael Luna (UT Southwestern) to discuss cardiovascular interventions during pregnancy. We discuss practical considerations for performing coronary angiography and valvular interventions in the pregnant patient, the timing and indication of procedures, and ways to minimize radiation exposure to both mom and baby. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.
This episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC.
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Pearls- Cardiac Interventions during Pregnancy
Attempt should be made to manage pregnant patients with valvular disease with medical therapy, and cardiac interventions during pregnancy should be considered a last resort.Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize fetal risk. Specific ways to minimize radiation to the pregnant patient and fetus in the catheterization lab include: using an abdominal shield, radial access for coronary procedures, proper positioning of the C-arm to avoid extreme angulation, using collimation, and minimizing fluoroscopic time, frame rate, and use of cine-acquisition. When appropriate, intracoronary imaging modalities (ie. IVUS or OCT) should also be considered.Fetal monitoring should be performed during any cardiac intervention in the pregnant patientMultidisciplinary involvement and contingency planning are critical for the success of any high-risk cardiac intervention in the pregnant patient.
Quatables - Cardiac Interventions during Pregnancy
“Meetings including all providers— our cardiac surgical colleagues, cardiac anesthesiologists, and our obstetrics team—in the care of [pregnant] patients has to be had well ahead of a cardiac procedure to plan every detail.”
Show notes - Cardiac Interventions during Pregnancy
1. What are special considerations for performing a balloon valvuloplasty in a pregnant patient with mitral stenosis?
In pregnant patients with severe mitral stenosis who cannot be adequately managed with medical therapy, percutaneous balloon mitral valvuloplasty (PMBV) is the treatment of choice given the high risk of morbidity and fetal loss with cardiac surgery.Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize risk to the fetus. Assessment of valve anatomy and consideration of the Wilkin’s score are especially important in pregnant patients to minimize the risk of peri-procedural complications.PBMV should performed at experienced centers with cardiac surgery and MFM available.Complications of PBMV are rare but include atrial perforation, cardiac tamponade, arrhythmias, emboli, mitral regurgitation, hypotension and maternal death. Mechanical support should be readily available and a delivery strategy in place in case there is sudden maternal or fetal deterioration.
2. What are ways to minimize radiation exposure in the catheterization lab to the pregnant patient and fetus?
The general principle for imaging during pregnancy is similar to imaging for the general population, with the goal of radiation exposure being as low as reasonably achievable (ALARA). The mean radiation exposure to the unshielded abdomen is 1.
166. CardioNerds Rounds: Challenging Cases of Hypertrophic Cardiomyopathy with Dr. Michelle Kittleson
Dec 09, 2021
CardioNerds Rounds Co-Chair, Dr. Karan Desai, joins Dr. Michelle Kittleson (Director of Postgraduate Education in Heart Failure and Transplantation, Director of Heart Failure Research, and Professor of Medicine at the Smidt Heart Institute at Cedars-Sinai) to discuss challenging cases of hypertrophic cardiomyopathy. As a guideline author on the 2020 ACC/AHA Hypertrophic Cardiomyopathy Guidelines, Dr. Kittleson shows us how the latest evidence informs our management of HCM patients, while sharing many #Kittlesonrules and pearls on clinical care. Come round with us today by listening to the episodes now and joining future sessions of #CardsRounds!
This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.
Speaker disclosures: None
Cases discussed and Show Notes • References • Production Team
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Show notes - Hypertrophic Cardiomyopaty Cases
Case #1 Synopsis:
Two non-white brothers in their early 20s come to clinic to establish care. They have no cardiopulmonary symptoms, normal EKGs and normal echos, but there was a possible family history of HCM. Their mother had LV hypertrophy and underwent septal myectomy, but she could not afford genetic testing and was no longer in the patients’ lives. The path report suggested “myocyte hypertrophy without disarray or bundles of myocytes.” How would you advise these patients regarding screening and surveillance? Listen to #CardsRounds for the full details!
Quotes from Case #1:
“Let’s take a walk down memory lane and let’s get to our evolution of understanding hypertrophic cardiomyopathy… [our understanding] follows the parable of the six blind men and the elephant. Each of the six blind man approached it from different angles, its tusk, its ear, its tail, and they all try to convince each other what an elephant is … because none of them can see the big picture.”
Dr. Kittleson on the history of HCM and coming to a unifying diagnosis
“The next time you are sitting there mashing your teeth because you have to memorize what the HCM murmur does squat to stand, Valsalva, or handgrip … remember you are standing on the shoulder of Giants. They [Drs. Braunwald and Morrow] pioneered surgical myectomy based on physical exam and cath lab findings”
Dr. Kittleson on the physical exam guiding HCM management
Takeaways from Case #1
Before we round, we think it is important to get on the same page regarding the nomenclature around HCM.
Since the original characterization of hypertrophic cardiomyopathy (HCM) more than 60 years ago (see the Braunwald Chronicles for the origin stories!), different terms have been used to describe the disease. These include idiopathic hypertrophic subaortic stenosis, hypertrophic obstructive cardiomyopathy (HoCM), and “burnt out HCM” when heart failure develops.The 2020 guideline committee recommended a common language to avoid confusion: since left ventricular (LV) outflow tract obstruction (LVOTO) occurs in >60% of patients over time, but one-third remain non-obstructive, the recommendation is t0 call the disease state HCM with or without outflow tract obstruction.Dr. Kittleson added that when heart failure develops we should characterize the pathology as HCM with heart failure rather than “burnt out HCM.”
Do we use HCM to describe any LV that has thick walls?
Some clinicians will use HCM to describe all disease states that can...
165. Narratives in Cardiology: Diversity & Inclusion Via Allyship & Leadership with Dr. Bob Harrington – California Chapter
Dec 02, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join CardioNerds Ambassadors Dr. Pablo Sanchez (FIT, Stanford University) and Dr. Christine Shen (FIT, Scripps Clinic) for a discussion with Dr. Bob Harrington (Interventional Cardiologist, Professor of Medicine, and Chair of the Department of Medicine at Stanford University) about diversity and inclusion in the field of cardiology. This episode discusses Dr. Harrington’s broader approach to mentorship, sponsorship, and allyship; and particularly how (and why) he used his position as the president of the American Heart Association to advocate against all-male panels, or “manels.” Listen to the episode to learn the background and motivations behind his evidence-based efforts to make Cardiology a more inclusive field. Special message by California ACC State Chapter President, Dr. Jamal Rana.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • References • Production Team
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Video version - Diversity and Inclusion
https://youtu.be/SnUadVRhH70
Quotables - Diversity and Inclusion
“If senior men don’t change the field, it’s not going to change. We have the senior positions. We have to change it.”“You’re missing talent. You’re missing talent of the women who have decided not to go into Cardiology. I say to a lot of my male colleagues...don’t you care about the health of our specialty? Don’t you want the very best people going into it?”“How great is that--to open up an artery in the middle of the night?... What could be better than that?...Why would you not want to be a cardiologist? Frankly, maybe the field is not so friendly to women...And that bothers me greatly because I love the specialty.”“To those who have been given much, much is expected. That’s what people like me should do.”Dr. Bob Harrington
Show notes - Diversity and Inclusion
What are the gender disparities in the field of Cardiology?
45.8% of residents and fellows in ACGME-accredited programs are women. 14.9% of cardiologists are women. 8% of interventional cardiologists are women [1]. 30.6% of male faculty were full professors, while 15.9% of female faculty are full professors [2].Men are more likely to be influenced by positive attributes of a field, while women are more likely to be influenced by negative attributes [3].3% of percutaneous coronary interventions in the United States are performed by female operators [4].
What is mentorship, sponsorship, and allyship?
A mentor provides advice and helps someone develop a skill.A sponsor is an advocate who helps someone secure career advancement opportunities.An ally partners with people, utilizing their power and influence to champion the rights of others [5].According to some studies, women report less sponsorship experiences than men. Additionally, in women it seems to translate less frequently into experiences that further their career (speaking engagements, serving on editorial boards, etc) [6].“I’m a mentor to a few people, I'm a sponsor to many, and I’m an ally to all.” - Dr.
164. Case Report: “A Good Candidate” Advanced Heart Failure in an 18-year-old Man with Autism Spectrum Disorder – Cleveland Clinic
Nov 30, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), are joined by guest host Dr. Alex Pipilas (CardioNerds Ambassader, Boston University), and Cleveland Clinic fellows, Dr. Gary Parizher, Dr. Ambreen Ali, and Dr. Tiffany Dong. They discuss a case of an 18-year-old man with Autism Spectrum Disorder presented with advanced nonischemic dilated cardiomyopathy. Due to anxiety, he was unable to tolerate right heart catheterization, and the initial evaluation for advanced heart failure therapies was deferred. With assistance from a multidisciplinary team, catheterization was successful, and he underwent cardiac transplantation. Faculty experts, Dr. Richard Dane Meredith (Cardiovascular Imaging, Mission healthcare), Dr. Julie Niezgoda (Congenital Cardiac Anesthesiologist, CCF), and Dr. Ran Lee (Critical Care Cardiology and Advanced HF/Transplant Cardiologist, CCF) provide the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
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Disclosures: NoneJump to: Pearls - Notes - References
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Case Media
Episode Teaching
Pearls - Heart Failure with Autism Spectrum Disorder
Autism spectrum disorder should not be regarded as a contraindication to organ transplantation.Respect for patient discomfort with procedures, and efforts to mitigate that discomfort, are essential.A multidisciplinary team approach, especially one utilizing allied health support services, is important to provide care to adolescent patients with advanced organ dysfunction, particularly those with developmental disabilities.
Notes - Heart Failure with Autism Spectrum Disorder
Autism spectrum disorder (ASD) is a developmental disability characterized by impairments in social interaction and the presence of restricted, repetitive patterns of behaviors, interests, or activities (2). In 2016 the CDC estimated one in 54 children age 8 had ASD (3). Despite ASD’s prevalence, studies of organ transplantation in children and adolescents with developmental disabilities are lacking. Guidelines from the International Society for Heart Lung Transplantation indicate that heart transplantation cannot be recommended in patients suffering from severe cognitive-behavioral disabilities (4). However, the definition of “severe” is not clear, so the assessment of severity of a cognitive impairment, as well as whether the impairment constitutes a contraindication to organ transplantation, falls to healthcare providers on a case-by-case basis.
Cardiac transplantation in a patient with ASD has been documented previously (5). Nonetheless our case represents an important example of advocacy for lifesaving care in patients with developmental disability. Without any one component of the team taking care of our patient, including physicians and allied healthcare providers, he would have died of refractory cardiogenic shock. However, with individualized care and a multidisciplinary combined effort, his providers were able to overcome the obstacles posed by his ASD and deliver indicated interventions.
References - Heart Failure with Autism Spectrum Disorder
1. Baran, David A., et al. "SCAI clinical expert consensus statement on the classification of cardiogenic shock" Catheterization and Cardiovascular Interventions 94.1 (2019): 29-37.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Arlington, VA: American Psychiatric Association, 2013.
3. Baio J, Wiggins L, Christensen D, et al. Prevalence of Autism Spectrum Disorder among children aged 8 years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries 2018; 67:1-23.
4.
163. Cardio-Obstetrics: Pregnancy and Anticoagulation with Dr. Katie Berlacher
Nov 25, 2021
Pregnancy is a hypercoagulable state associated with increased risk of thromboembolism. Managing anticoagulation during pregnancy has implications for both the mother and the fetus. CardioNerd Amit Goyal joins Dr. Akanksha Agrawal (Cardiology Fellow at Emory University), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), and Dr. Katie Berlacher (Program Director of the Cardiovascular Disease Fellowship and Director of the Women’s Heart Program at UPMC) as they discuss the common indications for anticoagulation and their management before, during, and after pregnancy. In this episode, we focus on management of pregnant patients with mechanical valves and venous thromboembolism.
Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
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Pearls- Pregnancy and Anticoagulation
Pregnancy is a hypercoagulable state. Pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.The use of anticoagulation requires a balance between the risks and benefits to the mother and her fetus.The agent of choice for anticoagulation during pregnancy depends on the indication, pre-pregnancy dose of vitamin K antagonist (VKA), and the trimester of pregnancy. For instance, patients with mechanical heart valves, warfarin is generally recommended in the first trimester if the daily dose is less than 5 mg and as the first option for all patients with mechanical valves in the 2nd and 3rd trimester. Use of direct oral anticoagulants (DOACs) has not been systematically studied, they do cross the placenta and their safety remains untested.Warfarin crosses the placenta but is not found in breast milk. LMWH does not cross the placenta and is not found in breast milk. Thus, both these agents can be used by a lactating mother.
Quatables - Pregnancy and Anticoagulation
“[We] can’t highlight enough that good communication and documentation is vital in such situations” says Dr. Berlacher while discussing the role of a multidisciplinary team including cardiologists, obstetricians and fetal medicine physicians in taking care of a pregnant patient on anticoagulation.
“What I love about cardio-obstetrics is that we really can help women in a time that is so important in their life…this is one of the most memorable times in their life..” says Dr. Berlacher when asked what makes your heart flutter about cardio-obstetrics.
“Knowledge is power...not just for providers, but also for the patients” says Dr. Berlacher emphasizing the importance of clear communication between physicians and patients.
Show notes - Pregnancy and Anticoagulation
1. What makes pregnancy a hypercoagulable state?
Pregnancy is a hypercoagulable state associated with higher risk of thromboembolic phenomenon. The three components of Virchow’s triad: hypercoagulability, stasis, and endothelial injury are all present during pregnancy. This leads to a 5-fold increased risk of venous thromboembolism (VTE) during pregnancy that persists for 12 weeks postpartum. The risk for VTE seems to be highest in the first 6 weeks postpartum, with a higher prevalence of clot in the left lower extremity.There are additional risk factors for developing VTE in the postpartum period besides pregnancy itself, and this includes but is not limited to preeclampsia, emergent c-section, hypertension, smoking, and postpartum infection.Choosing anticoagulant therapies during pregnancy involves a fine balance between the risks and benefits to both the mother and fetus. A multidisciplinary team involving the obstetrician, cardiologist, and maternal-fetal medicine team is critical to guide anticoagulation in pregnanc...
162. CCC: Critical Care Cardiology – A New Subspecialty for the Modern CCU with Dr. Jason Katz
Nov 22, 2021
The CardioNerds are thrilled to launch The Cardiac Critical Care Series! The series Co-Chairs – Dr. Mark Belkin (Advanced Heart Failure FIT, U Chicago), Dr. Yoav Karpenshif (FIT, U Penn), Dr. Eunice Dugan (CardioNerds Academy Chief Fellow and FIT, Cleveland Clinic), and Dr. Karan Desai (CardioNerds Academy Editor and FIT, U Maryland) - join CardioNerds Co-Founders, Amit Goyal and Daniel Ambinder to delve into high-yield topics in critical care cardiology.
We kickstart this series with one of the early pioneers and national leaders in cardiac critical care – Dr. Jason Katz, Director of Cardiovascular Critical Care and Co-Director of Mechanical Circulatory Support and the CICU at Duke University Medical Center.
In this episode, we learn about Dr. Katz’s career path and what motivated him to train in Critical Care Cardiology. He shares early struggles, notable changes in this field’s nascent period, and ongoing challenges in training and practice. We discuss collaboration with other cardiac and non-cardiac specialties and their importance in comprehensive care. Furthermore, we discuss how to advance critical care research, including the Critical Care Cardiology Trials Network and future randomized controlled trials to inform our practice and develop standardized protocols. In this small but rapidly growing field, we learn there is much to discover together. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.
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Pearls and Quotes
“I think it's really important not to be afraid of change in order to potentially succeed [...] it's okay to not entirely know what you want to do.” - Dr. Katz when sharing his non-direct career path in a novel field.“There is no greater team sport in cardiology than Cardiac Critical Care” and “I oftentimes think of the Critical Care Cardiologist as sort of the conductor that helps to orchestrate [the team]...” - Dr. Katz when discussing the importance of multidisciplinary teams and need to collaborate with other cardiac and non-cardiac sub-specialties.Many general surgical or medical residency/fellowship graduates are not comfortable caring for patients in the critical care setting. There is a need to revamp critical care training without significantly prolonging training time in order to complement and enhance our current workforce to care for complex, critically ill cardiac patients.“I don't think there's necessarily a one size fits all model, and I think we should be malleable or adaptable to the needs of our trainees and the needs of our patients.” - Dr. Katz when discussing training pathways in Critical Care Cardiology or combining Critical Care with other subspecialties like Interventional Cardiology or Advanced Heart Failure.Dr. Katz suggests that when choosing a Critical Care Cardiology training program: “consider geography, the flexibility of the curriculum, the overall fellowship and social experience, and the clinical setting. Everything that's really important to choosing a cardiology fellowship is more important in my mind than if they actually have a standardized, cardiac critical care pathway.”
Show notes
1. What are some recent changes in the field of Critical Care Cardiology?
Compared to even just a decade ago, there is a growing interest from medical students to young faculty in pursuing a career in critical care cardiology.At the same time there is evidence that the patient demographics in our CICUs are changing, including more multi-organ dysfunction and many non-cardiac diagnoses. In a recent paper from the Critical Care Cardiology Trials Network (CCCTN),
161. Lipids: EPA and DHA Deep Dive with Dr. Erin Michos
Nov 19, 2021
CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic) and Rick Ferraro (Director of CardioNerds Journal Club and cardiology fellow at the Johns Hopkins Hospital) join Dr. Erin Michos (Associate Professor of Cardiology at the Johns Hopkins Hospital and Editor-In-Chief of the American Journal of Preventative Cardiology) for a discussion about the effect of DHA and EPA on triglycerides and why DHA/EPA combinations may have exhibited limited benefits in trials. This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Relevant disclosures: None
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Pearls
The best intervention for heart disease is prevention! The InterHeart trial showed that 9 modifiable risk factors (dyslipidemia, smoking, hypertension, diabetes, abdominal obesity, dietary patterns, physical activity, consumption of alcohol, and psychosocial factors) predict 90% of acute myocardial infarction. So many acute events can be prevented1.Atherosclerotic vascular disease events increase across a range of triglyceride levels, even from 50-200mg/dL. So even in a relatively normal range, lower triglycerides seem to be better. Over ¼ of US adults have triglycerides over 150.While 8% of US adults take fish oil supplements, multiple meta-analyses have failed to show any benefit to the use of dietary omega-3 supplementation2. Dietary supplements these are not meant for medical use and are not studied or regulated as such!
Show notes
1. What are DHA and EPA?
DHA, or docosahexaenoic acid, and EPA, or eicosapentaenoic acid, are n-3 polyunsaturated fatty acids, also known as omega-3 fatty acids. These compounds have been of considerable interest for over two decades given observed association of high dietary omega-3 fatty acid intake with reduced cardiovascular events3. As both are important omega-3 fatty acids, trials on the benefits of DHA and EPA have often focused on the two compounds in combination.
2. What was the GISSI-Prevenzione Trial and why was it Important?
GISSI-Prevenzione trial (Lancet 1999), was one of the earliest trials to study DHA and EPA4. In this trial, the authors evaluated the effect of omega-3 supplementation as a combination pill of DHA and EPA on cardiovascular events and death in patients with recent myocardial infarction (the last three months). Over a 3.5-year follow-up period, participants treated with DHA/EPA combination experienced a significant reduction in death, nonfatal MI, and stroke.As this was an early trial, patients were largely not on statins, as these were not supported at the time of study initiation (Only 5% were on cholesterol-lowering medications at baseline, and only 45% were on cholesterol-lowering therapy at study completion). The benefits seen in this trial may not extend to modern practice with patients on contemporary background therapy.The trial participants were also not representative of our modern patients for a variety of other reasons. 85% of participants in the trial were men. 42.2% of patients in EPA/DHA arm were current smokers, and 35.4% were prior smokers. Only 14.2% of patients had diabetes and 14.7% with BMI >30.Notably, the decrease in triglycerides in this trial was only 3%, implying that triglyceride lowering did not entirely explain the benefit in cardiovascular events seen.
3. What about the data after the GISSI-Prevensione Trial?
After this positive trial for DHA/EPA in combination, subsequent trial data in support of DHA/EPA has been less robust.
160. Case Report: An Upstream Cause of Sudden Cardiac Arrest – Cedars-Sinai
Nov 16, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), join CardioNerds FIT Ambassador, Dr. Natasha Cuk and her co-fellows, Dr. Lily Stern, and Dr. Paul Marano from the Cedars-Sinai Cardiology Fellowship for some late afternoon smoothies on the beach. They discuss the case of a 46-year-old woman who presented with sudden cardiac arrest and was ultimately found to have a mobile intraluminal aortic thrombus adherent to a penetrating ulcer in the ascending aorta. This mobile thrombus was ultimately thought to be the cause of transient ischemia and the patient’s cardiac arrest. We discuss a differential for sudden cardiac arrest, initial management after resuscitated cardiac arrest, a differential for arterial thrombus, and review an illness script for penetrating atherosclerotic ulcers. Dr. Dominick Megna provides the provides the E-CPR for this episode. Audio editing by Dr. Gurleen Kaur (Director of the CardioNerds Internship).
This Case Report has been published in JACC Case Reports!
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Disclosures: NoneJump to: Pearls - Notes - References
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Episode Teaching
https://twitter.com/LilySternMD/status/1460811173113184263?s=20
Pearls - Cardiac Arrest due to Aortic Thrombus
After cardiac arrest, the initial ECG obtained after the return of spontaneous circulation can provide important information on the etiology of the arrest. The ECG can narrow our structured differential, for which one approach would be the following breakdown: acute ischemic events, structural heart disease, arrhythmogenic syndromes with no structural abnormality, and then non-cardiac causes such as drugs, toxins, trauma, metabolic arrangementsThe risk vs benefit of emergent angiography after sudden cardiac arrest depends on balancing the potential benefit from revascularization in an acute ischemic event vs bleeding risks and potential delays in other aspects of care, particularly given that a large percentage of mortality is related to neurologic injury from the arrest, which would not be impacted by immediate angiography. The available randomized controlled trial evidence has not demonstrated a survival or neurologic outcome benefit to immediate angiography, and the decision depends on weighing the risk/benefit for each patient.Due to high flow, a thrombus in the aorta should prompt an investigation for causes focused on the other two ‘points’ of Virchow’s triad (aside from stasis): endothelial injury and hypercoagulability.A penetrating atherosclerotic ulcer (PAU) is a deep atherosclerotic lesion where there is a focal ulceration of the elastic lamina that extends through the medial layer of the aortic wall. These lesions are most commonly associated with extensive atherosclerosis, but can also occur related to inflammatory, infectious, or traumatic causes.A PAU is a type of acute aortic syndrome and accounts for up to 8% of total acute aortic syndromes. It may present with a spectrum of symptoms, including as an incidental finding on cardiothoracic imaging or a severe chest and back pain, like an aortic dissection. While it is a subtype of aortic syndrome, PAU can also progress to become aortic dissection and rupture.
Notes - Cardiac Arrest due to Aortic Thrombus
1. How might a post-ROSC ECG help determine the etiology of a sudden cardiac arrest?
During our case, we discussed a systematic approach to the differential diagnosis for sudden cardiac arrest. We broke down the causes into the buckets of:
Acute ischemic eventsStructural heart diseaseArrhythmogenic syndromes with no structural heart diseaseNon-cardiac causes such as drugs, toxins, trauma, and metabolic arrangements
The post-ROSC ECG can provide immediate information to help narrow our diffe...
159. ACHD: Coarctation of the Aorta with Dr. Ari Cedars
Nov 10, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chair Dr. Agnes Koczo (UPMC), and episode FIT lead, Dr. Natasha Wolfe (Washington University) join Dr. Ari Cedars (Director of the Adult Congenital Heart Disease Program at Johns Hopkins) for a discussion about coarctation of the aorta.
In this episode we discuss the presentation and management of unrepaired and repaired coarctation of the aorta in adults. We discuss the unique underlying congenital anatomy of coarctation and how that impacts physiology, clinical presentation, and diagnostic findings. We discuss the importance of long-term routine follow-up and screening of patients (including those who have been “repaired”) for common complications such as hypertension, re-coarctation, and aneurysm development. We end with a discussion of treatment options for coarctation and its complications.
Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
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Pearls
Coarctation of the aorta can occur as a discrete stenosis or as a long and hypoplastic hypoplastic aortic arch segment. Most commonly it is a discrete stenosis located at the insertion site of the ductus arteriosus just distal to the left subclavian artery.Three quarters of patients with coarctation of the aorta also have a bicuspid aortic valve.Hypertension is the most common long-term complication of coarctation of the aorta, whether repaired or unrepaired. Unrepaired coarctation is a rare cause of secondary hypertension in young adults with a difference in upper extremity and lower extremity BP by ≥ 20 mmHg. Systemic hypertension may not be consistently identifiable at rest in those with repaired coarctation, thus guidelines recommend ambulatory blood pressure monitoring or stress testing to identify hypertension with exertion.Chest and brain imaging via CT or MRI should be done every 5-10 years to screen for other long-term complications including re-coarctation (rate ~11%), aortic aneurysm development (higher risk in those with concurrent bicuspid aortic valve), pseudoaneurysm, aortic dissection, and cerebral aneurysms.Repair of coarctation or re-coarctation is indicated for patients who are hypertensive with a BP gradient ≥ 20 mmHg (Class I recommendation). Catheter-based stenting is the preferred approach when technically feasible.
Show notes
1. What is the proposed embryologic origin of coarctation of the aorta?
The aortic arch and its branches develop at 6-8 weeks fetal gestation. We all start with six aortic arches that go on to become the great arteries of the head and neck. The 4th arch forms the thoracic aortic arch and isthmus. The 6th arch persists as the proximal pulmonary arteries and ductus arteriosus. Thoracic aortic coarctation is therefore a manifestation of abnormal embryologic development of the 4th and 6th arches.There are two main theories regarding how aortic coarctation occurs.
158. Cardio-Obstetrics: Pregnancy and Valvular Heart Disease with Dr. Uri Elkayam
Nov 04, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, and episode FIT lead and UT Southwestern Cardiology Fellow Dr. Laurie Femnou discuss valvular heart disease in pregnancy with cardio-obstetrics expert Dr. Uri Elkayam, Professor of Medicine and OB Gyn at the University of Southern California.
In this pearl-packed episode, we discuss the diagnosis, acute management, and long-term considerations of valvular heart disease in pregnancy. Through a series of cases, we review the physiologic changes in pregnancy that make certain valvular lesions well-tolerated, while others are associated with a much higher risk of peripartum complications. We also discuss which patients to consider referring for valvular intervention, the ideal timing, and which valvular interventions are safest in the peripartum period. We promise, you won’t want to miss this clinically high-yield episode with Dr. Elkayam, the father of cardio-obstetrics and an absolute legend in the field!
Audio editing by CardioNerds Academy Intern, Adriana Mares.
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Pearls
Most women with severe valvular heart disease can be managed medically throughout pregnancy.Right sided valvular lesions are generally better tolerated than left-sides lesions, and regurgitant lesions are generally better tolerated than stenotic lesions. However, the context and etiology of the valve dysfunction must be taken into consideration. Severe tricuspid valve regurgitation, for example, can be associated with a failing right ventricle and undiagnosed pulmonary hypertension. Changes in BNP, severity of symptoms, and right ventricular systolic pressure (RVSP) assessed by echocardiography can be helpful in differentiating normal pregnancy-related symptoms from symptoms due to hemodynamically significant valvular lesions.Valvular interventions during pregnancy are safe when well-planned and performed by experienced operators, and they can significantly improve morbidity and mortality in women who remain symptomatic despite medical management.A multidisciplinary team-based approach is important when managing patients with valvular heart disease during pregnancy.
Quatables
“We do not need to perform prophylactic valvular intervention in women prior to pregnancy if they do not meet criteria for intervention otherwise. A patient with regurgitant lesion will tolerate pregnancy well, provided that they are not candidates for surgery already.”
“Valvuloplasty during pregnancy is a great and effective procedure, but restenosis occurs. For women who desire future pregnancies, preconception evaluation is important to determine if valve intervention is indicated prior to conceiving.”
Show notes
What is the epidemiology of valvular heart disease in pregnancy?Cardiovascular conditions affect up to 4% of pregnancies, with valvular heart disease being the most common cardiac pathology encountered during pregnancy worldwide.In the developing world, rheumatic valve disease is still the most common etiology, with mitral valve most commonly affected, followed by the aortic valve.In the developed world, congenital aortic valve pathology is most common.
What are the hemodynamic effects of stenotic vs. regurgitant lesions during pregnancy?In normal pregnancy, there is a significant drop in systemic vascular resistance as early as 5 weeks gestational age. This drop leads to a transient decrease in perfusion to the kidneys, causing an increase in fluid retention and expansion of plasma volume. At the same time, there is an increase in heart rate which becomes more pronounced la...
157. Case Report: A Case of Complete Heart Block In A Young Adult – Stanford University
Oct 31, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), join CardioNerds FIT Ambassador, Dr. Pablo Sanchez, and his co-fellows, Dr. Jimmy Tooley and Dr. Maggie Ning from Stanford University for an important case discussion about an An otherwise healthy young adult presented with fatigue and was found to be in complete heart block due to sarcoidosis. Dr. Ronald Witteles, (Stanford University Program Director for the Stanford Internal Medicine residency program and advanced heart failure specialist who's particular expertise focuses in the treatment of amyloidosis, sarcoidosis, and cardio-oncology) provides the E-CPR for this episode.
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Disclosures: Dr. Witteles reports that he has served as an advisor for Pfizer, Alnylam, Eidos, Regerenon Pharmaceuticals, Janssen, and IonisJump to: Patient summary - Case teaching - References
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Patient Summary - Notes - Complete Heart Block due to Sarcoidosis
An otherwise healthy young adult presented with fatigue and was found to be in complete heart block. Imaging studies were suspicious for cardiac and pulmonary sarcoidosis. Sarcoidosis was confirmed on biopsy. Given the high risk of future cardiac events our patient underwent a dual chamber ICD implantation. He was started on prednisone and methotrexate for immunosuppression.
Case Media - Click to enlarge
Episode Teaching - Notes - Complete Heart Block due to Sarcoidosis
Pearls - Complete Notes - Complete Heart Block due to Sarcoidosis
Cardiac sarcoidosis is a disease characterized by noncaseating granulomas involving the heart that can exist alone or together with other organ system involvementDepending on the sites of cardiac involvement it can present as conduction system disease, ventricular arrhythmia, or heart failureCardiac sarcoidosis should be considered in patients with history of sarcoidosis involving other organ systems who develop left ventricular dysfunction, wall motion abnormalities, or arrhythmiasCardiac sarcoidosis should be considered in patients who present with otherwise unexplained heart block or ventricular tachycardia (VT) It is generally recommended that patients with cardiac sarcoidosis with an indication for pacemaker receive an ICD at time of implantation regardless of history of VT
Notes - Complete Heart Block due to Sarcoidosis
1. What is Sarcoidosis?
Sarcoidosis is a rare disorder of inflammation characterized by the formation of noncaseating granulomas in affected tissues. It most commonly involves the pulmonary system, but other organ systems can be involved including the heart. Sarcoidosis typically affects young adults, and its etiology is still uncertain.
2. What is Cardiac Sarcoidosis and how is it diagnosed?
Cardiac sarcoidosis (CS) can occur alone or with systemic disease and depending on the cardiac sites of involvement, can present as conduction system disease, ventricular arrhythmia, heart failure, or sudden cardiac death.
3. How is Cardiac Sarcoidosis diagnosed?
Diagnosis of CS is challenging as the gold standard is endomyocardial biopsy (EMB), though sensitivity of EMB is low given the often-patchy tissue involvement. Societal guidelines on the diagnosis of CS require either a positive EMB or biopsy-confirmed extracardiac sarcoidosis with evidence of secondary criteria to suggest cardiac involvement - unexplained VT, high grade AV block, third degree AV block, LVEF <40%, or characteristic imaging finding on cardiac MRI and cardiac PET.
The diagnosis of CS must be considered in all patients with a diagnosis of extra cardiac sarcoidosis who develop symptoms to suggest cardiac involvement. Additionally,
screening for CS should be done in all patients <60 years of a...
156. Lipids: Triglycerides – Pathophysiology to Clinical Outcomes with Dr. Matthew Budoff
Oct 18, 2021
CardioNerds Dan Ambinder, Dr. Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic), and episode lead, Dr. Teodora Donisan (CardioNerds Academy fellow and incoming Chief fellow and Beaumont Health Internal Medicine resident) join Dr. Matthew Budoff (professor of medicine at David Geffen School of Medicine at UCLA and the Endowed Chair of Preventive Cardiology at Harbor-UCLA Medical Center) for a discussion about triglycerides from pathophysiology to clinical outcomes. This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).
Triglyceride (TG) metabolism can produce a by-product called remnant lipoproteins, which can be atherogenic. Most guidelines consider hypertriglyceridemia to start at values ≥ 150 mg/dl. It is the most common dyslipidemia, as it can occur in 30% of the general population. Although fasting levels are usually obtained per the current US protocol, there is evidence that non-fasting TG levels might be a better indicator of cardiovascular (CV) risk as these levels may better reflect the usual levels that the body is exposed to. There are multiple primary (genetic) causes of elevated TG, but these are rarer than lifestyle factors, medical conditions, or medications. Genetic association studies are helping better define the level of CV risk stemming from elevated TG-levels, which will impact how we target lifestyle and treatment interventions in the future.
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Relevant disclosures: Dr. Matthew Budoff has funding from General Electric.
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Pearls - Triglycerides - Pathophysiology to Clinical Outcomes
In the process of metabolizing TG, remnant lipoproteins are formed, which have been shown to promote atherogenesis. TG themselves have not been directly linked to this process and have not been studied in large population studies, and so are considered risk enhancing factors, and not risk factors per se. Elevated triglyceride levels measured on our traditional lipid panels act as a proxy for the Apo-B rich lipoproteins, such as VLDL, which directly cause atherogenesis.Hypertriglyceridemia is defined as TG values of ≥150 mg/dl, although there is emerging evidence that even high-normal values (100-140 mg/dl) can still be associated with increased CV risk. You can think of TG in a similar fashion to glucose values (patients with prediabetes are still at higher CV risk than those with normal glycemic level). These are continuous and not binary variables!Fasting lipid levels are not necessarily a better predictor of CV events than non-fasting lipid levels. A non-fasting TG level can potentially provide information on the body’s metabolism similarly to how we interpret glucose tolerance tests, although there isn’t such a standardized approach in the lipid world yet.Before testing for genetic causes, make sure you review secondary causes of elevated TG. Don’t forget to evaluate for lifestyle factors and medical causes (diabetes, alcohol abuse, hypothyroidism, pregnancy) and to review the medication list (pay attention to thiazides, non-selective beta blockers, antipsychotics and others).TG values of ≥ 175 mg/dl are considered a risk enhancing factor and can aid in the decision to be more aggressive with lifestyle changes or starting treatment.Although treatment will be reviewed in depth in future episodes, Dr. Budoff suggests we “back away from using fibrates for CV event protection.” Even though they are efficient at lowering TG levels,
155. ACHD: Ebstein Anomaly with Dr. Jeannette Lin
Oct 15, 2021
CardioNerds (Amit Goyal and Josh Saef) join ACHD fellow Dr. Prashanth Venkatesh and ACHD program director Dr. Jeannette Lin, both from the University of California, Los Angeles, for a deep dive into the complex disease entity that is Ebstein anomaly. They discuss the anatomic features of the dysplastic tricuspid valve as well as the right ventricle in patients with Ebstein anomaly, and how these structural features affect cardiovascular physiology and clinical presentation. This is followed by an in-depth discussion into associated entities including arrhythmias and atrial-level shunts as well as the appropriate multimodality evaluation. Finally, they tackle the difficult question of when and how to intervene, delving into the various interventional treatments and exploring their outcomes using illustrative case-based examples. Audio editing CardioNerds Academy Intern, Pace Wetstein.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Claim free CME for enjoying this episode! Disclosures: None
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Pearls
Ebstein anomaly is characterized by an inherent myopathy which is often more clinically consequential than the more obvious tricuspid valvulopathy. This can affect not only the right ventricle due to ‘atrialization’ and severe tricuspid regurgitation (TR) but also the left ventricle that is often small due to chronic preload deprivation from reduced RV outflow (no flow, no grow)!Diagnosing severe TR on echocardiography in patients with Ebstein anomaly is challenging, due to the frequent absence of a clearly defined vena contracta and lack of hepatic vein systolic flow reversal. Be on the lookout for severe low gradient TR, which may manifest as a triangular doppler signal rather than the normal parabolic profile.If an electrocardiogram of a patient with Ebstein anomaly suggests prior inferior myocardial infarction, be very suspicious for a right-sided accessory pathway! These are seen in nearly a third of patients with Ebstein anomaly, and manifest as negative delta waves in the inferior leads, leading to a pseudo-infarct pattern. NOTE: infarction, aberrancy, and ventricular hypertrophy should not be coded in the presence of an accessory pathway (i.e., WPW pattern).Patients with Ebstein anomaly who are planned for tricuspid valve replacement should undergo an electrophysiology study preoperatively, since the cavo-tricuspid isthmus responsible for atrial flutter that plagues a large number (>20%) of these patients will be covered by a tricuspid prosthetic valve ring and be inaccessible for future catheter ablation.Certain patients with Ebstein anomaly with significant baseline RV dysfunction who require tricuspid valve surgery may benefit from a concomitant Glenn shunt, which is a surgical anastomosis of the superior vena cava to the right pulmonary artery. This relieves the dysfunctional RV of a third of its baseline preload, potentially enabling it to recover effectively from the stress of cardiopulmonary bypass.
Show notes
1.
154. Cardiology vs Nephrology: A Diuretic Showdown with Dr. Michael Felker & Dr. Matt Sparks
Oct 11, 2021
CardioNerds, Amit Goyal and Daniel Ambinder, join Duke University CardioNerds Ambassador and Correspondent, Dr. Kelly Arps for the diuretic showdown of a lifetime. Join us for this Cardiology vs. Nephrology discussion and respective approach to volume overload and diuretic strategies with Dr. Michael Felker (Professor of Medicine with tenure in the Division of Cardiology at Duke University School of Medicine), and Dr. Matt Sparks (Founding member of the Nephrology Social Medial Collective and #NephJC and Associate Professor of Medicine and Program Director for the Nephrology Fellowship Program at Duke University School of Medicine). Episode introduction, audio editing and Approach to Diuretic Resistance infographic by Dr. Gurleen Kaur (Director of the CardioNerds Internship).
Volume overload is a common indication for hospitalization in patients with heart failure. Loop diuretics are first line therapy for volume overload in heart failure, with assessment for adequate response within 3-6 hours after administration. Elevation in creatinine is common with venous congestion as well as during decongestion. While other causes of renal injury should be considered, an elevated creatinine in this context should not automatically trigger avoidance or cessation of diuresis. Diuretic resistance is an exaggerated form of natural safety mechanisms in the face of diuresis. Strategies for addressing diuretic resistance include optimizing dose and frequency of loop diuretic administration, adding adjunctive medication for sequential nephron blockade (i.e., thiazide diuretic, potassium sparing diuretic, acetazolamide, tolvaptan, SGLT2 inhibitor), and, in refractory cases, hemodialysis with ultrafiltration. In the outpatient setting, transition to a more potent loop diuretic (i.e., torsemide or bumetanide from furosemide), addition of a mineralocorticoid antagonist, or intermittent dosing of thiazide diuretic may augment maintenance diuretic therapy for patients with diminished response to loop diuretics.
Check out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content!
Relevant disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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The CardioNerds Heart Success Series is developed in collaboration with the Heart Failure Society of America. The Heart Failure Society of America is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
Pearls - Cardiology vs Nephrology: A Diuretic Showdown
Elevation in creatinine is expected in both congested states and during diuresis. Do not avoid or stop diuresis in a patient who is clearly volume overloaded based on an elevated creatinine. There may be a role for right heart catheterization if the fluid and/or hemodynamic status is unclear. Alkalosis in the setting of loop diuretic administration and diuretic resistance may represent a natural response to loop diuretics and not volume depletion. Ensure adequate potassium repletion and try using a mineralocorticoid antagonist to correct this alkalosis. Acetazolamide is rarely necessary but may be of use.Currently available evidence does not support extreme fluid or salt restriction in hospitalized patients with volume overload. Consider permissive restrictions and focus on choosing appropriate diuretic dosing for each individual patient. Diuretic resistance is an exaggerated form of diuretic braking, the kidney’s natural response to prevent dangerous degrees of sodium loss from the NKCC2-blocking effects of loop...
153. Case Report: Ur-Ine for a Treat – A Case of Diuretic Resistance – The Johns Hopkins Hospital
Oct 08, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), join Dr. Anjali Wagle (Internal medicine resident, Johns Hopkins Hospital) and Dr. Nick Smith (Cardiology fellow, Johns Hopkins Hospital) for an important discussion involving a patient with non-ischemic dilated cardiomyopathy and biventricular heart failure who had developed diuretic resistance. They discuss the role for invasive hemodynamic assessment of volume overload, initial strategies in managing a patient with volume overload, the role of guideline directed therapy in the management of patients with recurrent volume overload, and advanced strategies for diuretic resistance. Dr. Nisha Gilotra (Director of the Cardiac Sarcoidosis Program and assistant professor of medicine, Johns Hopkins Hospital) provides the E-CPR for this episode. Audio editing and Approach to Diuretic Resistance infographic by Dr. Gurleen Kaur (Director of the CardioNerds Internship).
This episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC.
Claim free CME just for enjoying this episode! Disclosures: NoneJump to: Patient summary - Case teaching - References
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Patient Summary - Diuretic Resistance
A young woman in her 20s with non-ischemic dilated cardiomyopathy and NYHA class IV ACC stage D biventricular heart failure with an LV ejection fraction of 30-35% on palliative inotropic therapy complicated by cardiogenic cirrhosis and stage IIIb chronic kidney disease presented with acute decompensated heart failure with volume overload. During her hospitalization she exhibited profound signs of diuretic resistance with minimal improvement after increasing inotropes, increasing IV loop diuretics, adding IV thiazides, and trialing continuous IV furosemide. She was given high dose mineralocorticoids, IV acetazolamide, and hypertonic saline paired with IV furosemide and had a durable treatment response.
Episode Teaching - Diuretic Resistance
Pearls - Diuretic Resistance
Diuretic resistance is a complex clinical problem defined as inadequate natriuresis despite an adequate diuretic regimen. However, the practitioner cannot overlook low output heart failure and/or insufficient renal perfusion as the causes for inadequate diuretic response. In cases of inadequate urine output due to low cardiac output, increased inotropic or mechanical support would be the first objective.Confirming adequate cardiac output to support renal perfusion and/or confirming high filling pressures may require invasive hemodynamic assessment.Sodium avidity is most effectively blunted by treating the patient with maximally tolerated guideline directed therapy. This includes but is not limited to a backbone of ARNI (or ACE or ARB), mineralocorticoid receptor antagonists, beta-blockers, and SGLT-2 inhibitors.In cases of advanced diuretic resistance, hypertonic saline paired with high dose IV furosemide can be an effective strategy.In cases of diuretic resistance combined with cirrhosis and heart failure there is a synergistic hyperaldosteronism that can be targeted with higher doses of mineralocorticoid receptors as is seen in the treatment of cirrhosis with ascites.
Notes - Diuretic Resistance
1. What is the role for invasive hemodynamic assessment in acute decompensated heart failure?
Cases where intracardiac filling pressures are in question: right heart catheterization (RHC) can give insight into the presence and degree of right versus left sided filling pressures.
152. Cardio-Obstetrics: Pregnancy and Multidisciplinary Critical Care with Drs. Afshan Hameed, Marie-Louise Meng, and Paul Forfia
Oct 04, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, episode lead fellow, Dr. Kaitlyn Ibrahim (Temple University now practicing with Lankenau Heart Group), join Dr. Afshan Hameed (Maternal-Fetal Medicine, Obstetrics & Gynecology, UC Irvine), Dr. Paul Forfia (Co-Director, Pulmonary Hypertension, Right Heart Failure & CTEPH Program, Temple University Hospital), and Dr. Marie-Louise Meng (Obstetric and Cardiothoracic Anesthesiology, Duke University) to discuss pregnancy and multidisciplinary critical care.
Three experts from varied subspecialties including Cardiology, Pulmonary Hypertension, Maternal Fetal Medicine, Cardiac Anesthesia and Obstetrical Anesthesia guide listeners through a case of a patient with a congenital conotruncal ventricular septal defect, Eisenmenger physiology, and pulmonary hypertension who becomes pregnant. The discussion touches on pre-conception risk assessment, pulmonary hypertension medical therapy in pregnancy, maternal monitoring during pregnancy, development of detailed multidisciplinary delivery plans and accessibility of such plans, and peri- and post-partum multidisciplinary management of high-risk patients.
Audio editing and episode introduction by CardioNerds Academy Intern, Christian Faaborg-Andersen.
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls
Cyanotic congenital heart disease presents multiple risks to the fetus, the most significant being intrauterine growth restriction. In a patient with Eisenmenger physiology, maternal oxygenation should be monitored closely throughout pregnancy, as hypoxia is often a marker of increased right to left shunting in these patients.In patients with pulmonary hypertension, the RV-PA coupling relationship is the best indicator of maternal cardiovascular reserve through the pregnancy and post-partum period. The goal of therapy is to get the pulmonary vascular resistance down to a point where the right heart can adapt to that load and function either at a normal or a near-normal level.When a high-risk patient meets with Anesthesia, it is important to consider the A’s: 1. Airway (anticipating any potential difficulties); 2. Access (whether this may present a challenge at the time of delivery); 3. Anxiety (specifically differentiating true hemodynamic changes in high-risk patients versus physiologic changes from anxiety); 4. Anticoagulation (knowledge of what agent the patient is on to determine safety of neuraxial anesthesia); 5. Availability (determining who else needs to be in the room, i.e. CT surgery, cardiothoracic anesthesia, ECMO team); 6. Arena (where is the safest place for this patient to deliver).In patients with a shunt who undergo a Cesarean section, the uterus should not be exteriorized due to risk of venous micro air emboli.As Dr. Forfia says, “panic is more dangerous sometimes than pulmonary hypertension!” Meaning, it is important to meet as a multidisciplinary team to develop a clear, easily accessible delivery plan for the patient. It is also prudent to have “everyone functioning in the environment they function best” like delivering the baby on the labor and delivery floor where all the necessary equipment and team members are available and bringing in other experts if needed rather than a cardiac operating room.
For a deep dive into Pregnancy & Pulmonary Hypertension, enjoy:
Episode #124 with Dr. Candice Silversides.Episode #144 – Case Report: A Mother with Shortness of Breath
Show notes
1. How does a multidisciplinary team play a role in the care for a high risk cardio-obstetrics patient, particularly one with congenital heart disease and pulmonary...
151. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 6 – Mentorship & The Secret to Immortality
Sep 30, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series.
In part 6 Dr. Packer reflects on a conversation he had with Dr. Eugene Braunwald about mentorship and its role in immortality. This episode is particularly meaningful to the CardioNerds team as mentorship and sponsorship is such an important part of the CardioNerds mission.
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
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CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
150. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 5 – The Ejected Fraction Of A Destroyed Heart
Sep 27, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series.
In part 5, Dr. Packer shares his thoughts on the term “guideline directed medical therapy,” guidelines in general, and the challenges of using the ejection fraction to measure systolic function.
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
CardioNerds Heart Failure Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
149. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 4 – SGLT2 Inhibitors – Under-Promised & Over-Delivered
Sep 27, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series.
In part 4, Dr. Packer shares his perspective on the revolutionary SGLT2 inhibors. We discuss the mechanisms of action and the data regarding their role in the care of heart failure patients. This episode is particularly historic in that Dr. Packer shares his thoughts about the EMPEROR-PRESERVED trial well before the data was available. Also see Dr. Mark Belkin's DocWire News article EMPEROR’s New Groove? Empagliflozin Provides Long-Awaited Treatment for HFpEF where Dr. Packer is quoted as saying “we are pleased to have the first trial in patients with HFpEF that shows an unequivocally positive and clinically important result. We are looking forward to many secondary papers that will provide detailed information about what we have found, and what it means for patients.”
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
CardioNerds Heart Failure Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
148. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 3 – Neutral Trials, A 2nd Chance, & A Paradigm Shift
Sep 20, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series. In part 3 Dr. Packer reflects on the value of neutral trials and recounts the journey that led to the PARADIGM Trial
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
CardioNerds Heart Failure Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
147. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 2 – The Secret To Happiness, The “Aha” Moment, & The Birth Of The Neurohormonal Hypothesis
Sep 20, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series. In part 2 Dr. Packer shares his journey as the trailing spouse and tells the story of how the neurohormonal hypothesis was developed.
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
CardioNerds Heart Failure Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
146. The Evolution Of The Neurohormonal Hypothesis With Dr. Milton Packer: Part 1 – Taking Risks, Upsetting People, & Disrupting The Status Quo
Sep 19, 2021
CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series.
In part 1 Dr. Packer discusses taking risks, upsetting people and the ridiculousness of humanity and how stand-up comedy helped contribute and shape his career in cardiovascular medicine. Dr. Packer also discusses how the study of afterload agents in heart failure and the discovery of tachyphylaxis with prazosin helped inspire a long and prosperous career in academic cardiology by changing the status quo.
Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!
This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.
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CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
145. ACHD: Pregnancy and Congenital Heart Disease with Dr. Carole Warnes
Sep 14, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chair Dr. Agnes Koczo (UPMC), and ACHD FIT lead Dr. Katia Bravo (UCLA) join ACHD expert Dr. Carole Warnes (Professor of Medicine and founder of the Adult Congenital Heart Disease Clinic at Mayo Clinic), to discuss adult congenial heart disease and pregnancy. They cover preconception counseling in women with congenital heart disease, appropriate risk stratification to estimate maternal and neonatal morbidity using existing tools and an individualized care approach and preparation for a multidisciplinary delivery plan. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.
The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more
Claim free CME for enjoying this episode! Disclosures: None
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls
Women with congenital heart disease can safely carry a pregnancy if appropriate risk stratification and management is performed by an expert multidisciplinary cardio-obstetrics team.There are a myriad of hemodynamic and vascular changes which impact congenital cardiac physiology and evolve throughout the different stages of pregnancy. Therefore, planning is key. An evaluation of heart rate response to exercise and optimization of potential factors that could worsen during pregnancy, such as arrhythmias, are recommended.Maternal morbidity & mortality risk-stratification systems such as the modified WHO, CARPREG or ZAHARA criteria are helpful starting points. Ultimately, each patient requires individualization given the heterogeneity that exists among congenital heart defects.Vaginal delivery is generally preferred over C-section from a cardiac standpoint. An assisted second stage of labor during the period of greatest hemodynamics changes should also be considered if vaginal delivery is pursued.
Show notes
Pregnancy and Adult Congential Heart Disease: Created by Dr. Katia Bravo and Dr. Teodora Donisan and reviewed by Dr. Candice Silversides
1. Why is preconception counseling important in women with congenital heart disease and what does it entail?
Ensuring women with congenital heart disease are optimized prior to conception decreases maternal and neonatal complications. For this reason, preconception counseling is paramount for these patients.In addition, counseling leads to patients making more informed decisions about family planning.The integral parts of preconception counseling include: (1) discussing the current anatomical and physiological status, (2) discussing possible complications during pregnancy specific to the patient's congenital heart defect (with genetic counseling referral if appropriate), (3) evaluating cardiac medications, taking into account benefits vs teratogenic potential, (4) discussing and planning for necessary pre-pregnancy tests or interventions (exercise stress testing is an important tool in evaluating how the patient will tolerate the stressors of pregnancy), (5) organizing antepartum care with high-risk obstetrics teams, (6) discussing location,
144. Case Report: A Mother with Shortness of Breath – Pushing Against All Odds – Allegheny General Hospital
Sep 05, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Kushani Gajjar and Dr. Mitha Naik from the Allegheny Health Network for a walk along the Three Rivers Trail in Pittsburgh. They discuss a case of young woman in her third trimester of pregnancy with a known history of pulmonary arterial hypertension. The management of pulmonary hypertension in pregnancy and RV failure in the context of pregnancy is described. The E-CPR segment is provided by Dr. Nandita Scott, Co-Director Corrigan Women's Heart Health Program and Cardiovascular Disease and Pregnancy Service at Massachusetts General Hospital. Special cameo appearance by Dr. Dani Crousillat.
If you’re a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page.
Claim free CME just for enjoying this episode! Disclosures: None
Jump to: Patient summary - Case media - Case teaching - References
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Patient Summary - Pulmonary Hypertension in Pregnancy
A 33-year-old woman in the third trimester of pregnancy, with a known history of untreated PAH in the setting of TKI therapy, presents with shortness of breath. She is found to have PA pressure greater than systemic pressure with PASP >130. We describe the management of PH and RV failure in the context of a pregnancy. The patient was admitted to the ICU where a multidisciplinary team was mobilized, involving high risk ob-gyn, maternal fetal medicine, critical care, anesthesiology, and advanced heart failure. They began pulmonary vasodilators including treprostinil, tadalafil and inhaled nitric oxide. They also added inotropic and vasopressor support for right ventricular dysfunction with her severe PAH. Fetal heart monitoring was performed. PAH also led to worsening of known chronic thrombocytopenia in the setting of CML. HELLP syndrome was ruled out. The patient had preterm rupture of membranes at 32 weeks of gestation and the team pursued assisted vaginal delivery to prevent vagal response. Following successful delivery, the patient elected to undergo intra-uterine device placement. Post-delivery, vasopressors and inotropes were weaned, and she was discharged on treprostinil, ambrisentan and tadalafil. Thankfully both the mother and baby returned healthy and well at 1 month follow up.
Case Media - Pulmonary Hypertension in Pregnancy
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Episode Teaching - Pulmonary Hypertension in Pregnancy
Pearls - Pulmonary Hypertension in Pregnancy
Pulmonary Hypertension is defined as a mean pulmonary arterial pressure (mPAP) of >20mmHg. There are 5 major types of pulmonary hypertension. Risk modifiers include symptom burden, exercise capacity, presence of pericardial effusion, RV function and hemodynamics.Multidisciplinary care teams are the key to achieving optimal pregnancy outcomes in patients with PH. It is critical to create a team of experts with experience in pulmonary hypertension and plan for constant communication before, during, and after pregnancy.Pregnant women who are already on PAH therapy outpatient should continue them during pregnancy (under the direction of PH experts) except for endothelin receptor blockers which fall in pregnancy category X.PH during pregnancy is associated with up to 38% maternal mortality rate as the right ventricle (RV) is often unable to handle the volume shifts and hemodynamic changes that occur during pregnancy, labor, and delivery.Patients with RV failure leading to low cardiac output and hypotension, like in this case,
143. Lipids: (Non)-Fasting LDL & Furious Lipid Lowering with Dr. Alison Bailey
Sep 01, 2021
CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins, and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic, learn all about the clinical application of the ASCVD primary and secondary prevention guidelines in terms of lifestyle modifications and lipid lowering strategies from Dr. Allison Bailey, Editor-in-Chief of the ACCEL Audio Journal and Advanced Heart Failure and Transplant Cardiologist at Centennial Heart. Dr. Baily was a co-author on the 2018 ACC/AHA Guideline on the Management of Blood Cholesterol.
In this episode we will learn about the current guidelines for primary prevention of ASCVD, the evidence for specific dietary changes in improving cardiovascular outcomes, the current guidelines for secondary prevention of ASCVD, how successful are clinicians and patients in meeting LDL-C recommendations, and what the recent SAMSON trial teaches us about statin intolerance.
If you're a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page.
Relevant disclosure: None
Pearls • Notes • References • Guest Profiles • Production Team
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Qoatables - Lipid Lowering with Dr. Alison Bailey
“Lifestyle should be the first step and the last step of everything we do.”
Pearls - Lipid Lowering with Dr. Alison Bailey
In patients without established clinical ASCVD, the percent reduction in LDL-C is the strongest predictor of cardiovascular benefit. In patients with high LDL-C levels, a 50% reduction in LDL-C levels should be targeted.In high-risk patients with established clinical ASCVD, we should target a 50% reduction in LDL-C levels and an LDL-C level less of than <70mg/dL. Lower LDL-C levels are associated with better ASCVD outcomes, and European guidelines recommend targeting an LDL-C level of <55mg/dL.LDL-C lowering starts with promoting a health-lifestyle with emphasis on regular exercise and heart-healthy diet. Randomized trials support the efficacy of the Mediterranean diet in reducing cardiovascular events.
Show notes - Lipid Lowering with Dr. Alison Bailey
1. What are the current guidelines for primary prevention of ASCVD?
The 2019 ACC/AHA Guidelines on the primary prevention of Cardiovascular Disease provides the following guidance for clinicians (applicable to those without established clinical ASCVD):For all patients, a heart-healthy lifestyle focused on diet and exercise is the most important way to prevent atherosclerotic disease.For any patient with an LDL-C ≥ 190 mg/dL, a high intensity statin is recommended.Patients aged 40-75 years old who have diabetes mellitus warrant at least a moderate intensity statin, and may benefit from a high-intensity statin based on additional risk factorsFor patients aged 40-75 years old and with an LDL-C between 70-189 mg/dL without diabetes, the pooled cohort equation can determine 10-year ASCVD risk and guide a patient-centric risk discussion.Percent reduction in LDL-C is the strongest predictor of cardiovascular benefit; a 50% reduction in LDL-C should be targeted for most patients.
2. What evidence exists for specific dietary changes in improving cardiovascular outcomes?
A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors. Additionally, minimizing intake of processed meats, refined carbohydrates, and sweetened beverages can reduce ASCVD risk.
142. HF part 11: The Role of the Clinical Examination in Patients With Heart Failure – with Dr. Mark Drazner
Aug 24, 2021
CardioNerds Amit Goal, Daniel Ambinder, & Dr. Alex Pipilas (FIT, Boston University) discuss the clinical examination in patients with heart failure with Dr. Mark Drazner, professor of medicine, clinical chief of cardiology, and medical director of the LVAD and Cardiac Transplantation Program at UT Southwestern. In this pearl laden episode, they discuss how the exam can be used to non-invasively assess a patient's hemodynamic status, risk stratify and inform prognosis, and guide management. They also discuss ways to master the evaluation of the JVP and categorize patients based on their RA:PCWP ratio.
Check out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content!
Relevant disclosures: None
The CardioNerds Heart Success Series is developed in collaboration with the Heart Failure Society of America. The Heart Failure Society of America is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.
This episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC.
Pearls • Notes • References • Guest Profiles • Production Team
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Pearls - Clinical Examination in Heart Failure
Begin hemodynamic assessment with the evaluation of congestion (“wet” vs “dry”) and perfusion (“cold” vs “warm”). In a 2x2 table, this breaks patients into 4 broad hemodynamic profilesThe most sensitive markers of congestion (PCWP > 30) are JVP >12 with an OR of 4.6 and the presence of orthopnea with an OR of 3.6“If you are cold, you are cold, if you are warm, you can still be cold”. Sensitivity for clinical markers of low cardiac index is very poor. Consider a low output state in patients with poor response to what are thought to be appropriate therapiesMost patients with acute on chronic heart failure have an RA:PCWP ratio of 1:2. These patients are the so called “concordant” phenotype. There are two other sub-phenotypes:The “RV equalizer group” have an elevated RA:PCWP ratioThe “RV compensated” group have a lower RA:PCWP ratioClinical congestion at the time of hospital admission as well as discharge portends a poor prognosis for patients with heart failure
Show notes - Clinical Examination in Heart Failure
Figure 1
1. What is the physical exam important in patients with heart failure?
Important to view the physical exam as a diagnostic test with strengths and limitationsIt is a noninvasive way to assess hemodynamics and risk stratify patientsCan provide information on prognosisMay enhance the provider-patient relationship
2. How might we classify hemodynamics noninvasively?
Framework begins with the “Stevenson” Classification, developed by Dr. Lynne StevensonClassifies patients along two axes: congestion and perfusionCongestion is the assessment of overall volume status and estimation of right and left sided filling pressures, broadly broken up into “wet” or “dry”:“Wet”, PCWP >15mmHg“Dry”, PCWP <15mmHgPerfusion is the assessment of the adequacy of cardiac output to provide oxygen to peripheral tissues, broken up into “warm” (i.e adequate perfusion) or “cold” (i.e poor perfusion):“Warm”, Cardiac index >2.2“Cold”, Cardiac index <2.2You then develop a 2x2 table to begin hemodynamic assessment (Figure 1 - above)
3.
141. Narratives in Cardiology: Empowerment & Growing Together as Women in EP with Dr. Kamala Tamirisa – Texas Chapter
Aug 17, 2021
In the PA.ACC – CardioNerds Narratives in Cardiology episode, CardioNerd Amit Goyal joins Dr. Miranda Merrill (FIT, Oregon Health & Science University), Dr. Stephanie Fuentes Rojas (FIT, Houston Methodist Hospital), and Dr. Natasha Cuk (FIT, Cedars-Sinai Medical Center) for a discussion with Dr. Kamala Tamirisa (Clinical Cardiac Electrophysiologist, Texas Cardiac Arrhythmia, National ACC Women in Cardiology Leadership Council Member and Co-Chair for ACC Women in Cardiology Advocacy Work Group, and current co-chair of the Texas Chapter ACC EP section) about gender equity and women in cardiology and electrophysiology. This episode focuses on the experiences of women in cardiology across the spectrum of training, from medical school, fellowship, through the procedural field of electrophysiology, to local and national leadership and beyond. Listen to the episode to learn about the factors which have led to Dr. Tamirisa’s success as a private practice electrophysiologist incorporating leadership roles in medical education and national organizations. Closing remarks by Texas ACC chapter governor, Dr. Kenneth Shaffer. Episode script was developed by Dr. Miranda Merrill and episode notes were developed by Dr. Natasha Cuk.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Video Version • Notes • References • Production Team
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Video version - Women in EP
https://youtu.be/e7Cjv4vPXqg
Quotables - Women in EP
“The exciting part today is to see three women who are interested in EP… like RBG said, when all EP physicians are women, that’s the day we’re going to celebrate” 07:15
“There's nothing (more) exciting… than EP, just that technology, the marriage between analytical thinking, tactile, touch, with a deductive logic.” 09:18
“Multiple studies have documented sex disparities in cardiovascular care… (Historically) women and minorities did not receive implantable cardioverter defibrillators or even BiV (biventricular) pacers… a potential driver for these disparities in cardiovascular disease is lack of diversity in the workforce. Very simple.” 19:28
“I still want to wear my lipstick. I still want to wear my heels. I want to do my hair. I still want to be a proceduralist and that's okay. Make room.” 28:00
Show notes - Women in EP
While this episode and the following notes are specific to women in electrophysiology, these same basic principles apply to fostering a more inclusive and welcoming environment in other subspecialties for all persons regardless of sex, gender, race, ethnicity, IMG status, and the other factors which make us different from one another and which enrich our workforce.
1. Why choose electrophysiology?
An EP career is unique – it combines the biology, physiology, and procedural skills learned in residency and fellowship training with engineering, mathematic, and imaging principles learned and refined in advanced EP fellowship.1EPs work in a spectrum of settings and with a spectrum of modalities: inpatient, outpatient clinic,
140. Lipids: LDL, Cardiovascular Events, & Disparities in Care with Dr. Keith Ferdinand
Jul 30, 2021
CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic join Academy fellow and episode lead Dr. Julie Power, chief fellow at the University of Minnesota to learn all about the link between LDL-C and cardiovascular events and disparities in care from Dr. Keith Ferdinand, Professor of Medicine and Chair in Preventative Cardiology at Tulane University School of Medicine.
As we’ve learned in prior episodes, LDL-C plays a key role in lipid pathophysiology. But how does it lead to cardiovascular events? LDL-C directly leads to plaque expansion and deposition in the arterial intima. Increasing levels of LDL-C are directly related to worsening plaque burden, a principle exhibited powerfully by the dose-dependent nature of coronary atherosclerosis in patients with underlying mutations leading to LDL-C elevation, such as familial hypercholesterolemia.
Importantly, the treatment of atherosclerosis and implementation of lipid-lowering therapies are not uniform, with significant disparities throughout the community. The message is clear: Reducing LDL-C is of paramount significance in the prevention and treatment of coronary atherosclerosis and ensuring equitable access to care is critical to addressing the societal burden of cardiovascular disease and improving the health of our communities.
There is no CME associated with this episode. To get free CME from other CardioNerds episodes, please visit VCU Health here.
Relevant disclosure: Dr. Ferdinand reported severing as a consultant for Medtronic, Amgen, and Novartis.
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Pearls - LDL, Cardiovascular Events, & Disparities in Care
LDL-C is a major stimulant for the initiation and progression of atherosclerosis.The lower the LDL-C level, the greater the clinical benefit in both primary and secondary ASCVD prevention.Our healthcare systems continue to have major disparities in access to quality care and it is essential to reduce barriers to cardiovascular wellness for all communities.Lowering LDL-C in individuals at high cardiovascular risk, especially in those with familial hypercholesterolemia, prevents ASCVD events.
Quotables - LDL, Cardiovascular Events, & Disparities in Care
“Empower patients to be partners in their care” Dr. Keith Ferdinand
Show notes - LDL, Cardiovascular Events, & Disparities in Care
1. What is the link between LDL-C and cardiovascular events?
LDL-C is a major stimulant for the initiation and progression of atherosclerosis. The key events in the initiation of ASCVD are the retention and accumulation of cholesterol-rich lipoproteins within the arterial intima at sites with a predilection for plaque formation. As serum levels of LDL-C increase, the probability of intimal retention of LDL leading to the development of atherosclerotic plaque increases in a dose-dependent manner [4].The WOSCOPS trial demonstrated genes associated with lower LDL-C levels are also associated with a three-fold reduction in the risk of cardiovascular disease per unit reduction in LDL-C [4].The Emerging Risk Factors Collaboration (ERFC) and Prospective Studies Collaboration reported plasma LDL-C was associated with increased risk of non-fatal MI or CHD death [4].Statins uniformly reduce atherosclerotic risk across varying levels of baseline LDL-C and are first line therapy for primary and secondary prevention of ASCVD.In high-risk individuals and secondary prevention populations, AHA/ACC guidelines recommend 50% reductions in LDL-C, regardless of baseline, to < 70 mg/dL,
139. Narratives in Cardiology: International Medical Graduates in the Cardiology Workforce with Dr. William Zoghbi
Jul 26, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join fellow lead, Dr. Giselle A. Suero-Abreu (FIT, Massachusets General Hospital), Dr. Isadora Sande Mathias (FIT, Houston Methodist and CardioNerds Academy Fellow), and Dr. Victor Nauffal (FIT, Brigham and Women's Hospital) for a discussion with Dr. William Zoghbi (Chair, Department of Cardiology, Houston Methodist Hospital, Methodist DeBakey Heart & Vascular Center, Past President, the American College of Cardiology) about international medical graduates in the cardiology workforce. This episode focuses on the narratives of international medical graduates (IMGs) who make important contributions to the US medical workforce and scientific innovation. Listen to the episode to learn the state of IMGs in the US physician workforce and the field of Cardiology, an overview of factors that influence IMG selection when applying to residency and fellowship training programs in the US, the impact of recent changes in licensing exams and immigration restrictions, and how to address challenges and support IMGs throughout their medical careers. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
Claim free CME just for enjoying this episode! Disclosures: None
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Show notes
1. What is the definition of an international medical graduate (IMGs)?
International medical graduates (IMGs) are physicians who who graduated from a medical school outside the United States, regardless of nationality.
This group of foreign-trained physicians include US-IMGs (US citizens) and non-US IMGs (non-US citizens). Nearly 80% of IMGs are born abroad [1].
In a paper senior authored by Dr. Zoghbi, IMGs in the US physician workforce are described as “the multicultural, multiethnic, open-minded, and plural fabric that has defined American medicine and contributed to its success over the years” [2].
2. Why are IMGs important?
IMGs are an integral part of the U.S. healthcare system. They constitute about 25% of the physician workforce and, since 2010, the number of IMGs in practice has grown by nearly 18% [1, 3].
IMGs play a critical role in addressing healthcare inequities across the US, comprising a significant proportion of physicians in high-need rural and underserved urban areas [1, 3, 4].
IMGs contribute to the diversity and cultural competence in the US physician workforce with 98% of them speaking two or more languages fluently. They help patients overcome linguistic and cultural barriers that can interfere with their care [5]. Learn more about Diversity and inclusion (Episode 95) and Latinx representation in cardiology (Episode 129).
Racial and ethnic concordance between physicians and their patients results in improved healthcare outcomes, and IMGs are essential in matching the needs of the increasingly diverse US population [6].
Many IMGs pursue the opportunity to train in the best academic programs in the US and return as leaders to serve their country. This becomes an avenue for international collaboration to help patients and contribute to research, innovation, and education.
3. What is the state of the IMG workforce in Cardiology?
IMGs in cardiology serve as an important source of cardiac care in the United States.
Data from the 2020 Physician Specialty Data Report from the Association of American Medical Colleges (AAMC) [7] showed that:
Among active US physicians, IMGs comprise 31% of general cardiologists, 46% of interventional cardiologists, and 26% of pediatric cardiologists.Among ACGME trainees, IMGs constitute 38% of fellows in cardiovascular disease, 53% in interventional cardiology, and 20% in pediatric cardiology.Many IMGs have non-immigrant visas, including the J-1 Visitor Exchange visa,
138. Lifelong Advocacy for Women’s Cardiovascular Health with Dr. Sharonne Hayes and Dr. Nanette Wenger
Jul 21, 2021
CardioNerds Cardio-OB series co-chairs University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah (FIT, University of Texas Southwestern) and Dr. Natalie Stokes, (FIT, University of Pittsburgh) join Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine and a consultant to the Emory Heart and Vascular Center and Dr. Sharonne Hayes, Professor of Internal Medicine and Cardiovascular Diseases and founder of the Women’s Heart Clinic at Mayo Clinic for an in depth discussion about lifelong advocacy for women's cardiovascular health.
Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
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Guest Profiles - Advocacy for Women's Cardiovascular Health
Dr. Nanette Wenger
Dr. Nanette Wenger is Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger received her medical degree from Harvard Medical School in 1954 as one of their first female graduates followed by training at Mount Sinai Hospital where she was the first female to be chief resident in the cardiology department. She is among the first physicians to focus on heart disease in women with an expertise in cardiac rehabilitation and geriatric medicine.Dr. Wenger has received numerous awards including the Distinguished Achievement Award from the Scientific Councils of the American Heart Association and its Women in Cardiology Mentoring Award, the James D. Bruce Memorial Award of the American College of Physicians for distinguished contributions in preventive medicine, the Gold Heart Award, the highest award of the American Heart Association, a Lifetime Achievement Award in 2009 and the Inaugural Bernadine Healy Leadership in Women’s CV Disease Distinguished Award, American College of Cardiology. She chaired the U.S. National Heart, Lung, and Blood Institute Conference on Cardiovascular Health and Disease in Women, is a Past President of the Society of Geriatric Cardiology and is past Chair, Board of Directors of the Society for Women’s Health Research. Dr. Wenger serves on the editorial boards of numerous professional journals and is a sought-after lecturer for issues related to heart disease in women, heart disease in the elderly, cardiac rehabilitation, coronary prevention, and contemporary cardiac care. She is listed in Best Doctors in America.
Dr. Sharonne N. Hayes
Sharonne N. Hayes, M.D., studies cardiovascular disease and prevention, with a focus on sex and gender differences and conditions that uniquely or predominantly affect women. With a clinical base in the Women's Heart Clinic, Dr. Hayes and her research team utilize novel recruitment methods, social media and online communities, DNA profiling, and sex-specific evaluations to better understand several cardiovascular conditions. A major area of focus is spontaneous coronary artery dissection (SCAD), an uncommon and under-recognized cause of acute coronary syndrome (heart attack) that occurs predominantly in young women. Dr. Hayes also studies the diagnosis and treatment of nonobstructive (microvascular) coronary artery disease and chest pain syndromes and the subsequent risk of arrhythmias and other cardiac conditions in women who have had hypertension, diabetes or preeclampsia during a pregnancy. With the Pericardial Disease Study Group, Dr. Hayes is assessing the optimal management of pericarditis. Additionally, Dr. Hayes is involved in several research initiatives aimed at addressing health equity and reducing health disparities. Through partnerships with national professional women- and minority-serving organizations, Dr. Hayes assesses barriers faced by women and minorities that prevent or deter them from participa...
137. WomenHeart Champions: Patients As Support and Advocates for Women With Heart Disease
Jul 19, 2021
In this special CardioOB series patient perspective episode, CardioNerds (Amit Goyal and Daniel Ambinder), join three incredible WomenHeart Champions, Ms. Porothea Dennis, Ms. Brandie Taylor, and Ms. Ellen Robin in the presence of two legendary leaders in cardiovascular medicine, Dr. Nanette Wenger and Dr. Sharonne Hayes. In addition to this episode being featured on our Cardio-Obstetrics topic page, you can also find this episode in our Patient and Family Perspective collection which features several moving and meaningful patient and family stories that remind us of why we do what we do. Special message by Ms. Celina Gorre, CEO of WomenHeart. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
The CardioNerds Cardio-Obstetrics series is a comprehensive series led by series co-chairs Dr. Natalie Stokes CardioNerds ambassador from UPMC and Dr. Sonia Shah CardioNerds ambassador from UTSW, and produced in collaboration with WomenHeart.
There is no CME for this episode. Relevant disclosures: None.
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Why Cardio-Obstetrics❓ Because it’s important, and relevant to anyone taking care of women who are, may become, or have been pregnant as cardiovascular disease is the #1 cause of pregnancy-related death.
In order to raise awareness we’ve put together an fun, sometimes sobering, but comprehensive curriculum, so get ready, because this CardioNerds Cardio-Obstetrics cruise will dock at several ports along the way: ✔normal pregnancy physiology, ✔hypertensive disorders, ✔arrhythmia, ✔valvular heart disease, ✔anticoagulation, ✔pulmonary hypertension, ✔congestive heart failure, ✔aortopathies, ✔coronary artery disease, ✔critical care, ✔4th trimester, ✔Racial disparities in care, ✔interventional considerations, ✔patient perspectives including from womenheart champions, and more!
CardioNerds Cardioobstetrics Production Team
Natalie Stokes, MDSonia Shah, MDAmit Goyal, MDDaniel Ambinder, MD
Join CardioNerds for a great discussion about key ACC 2021 Prevention highlights featuring the ADAPTABLE and STRENGTH trials. This episode is produced in collaboration with the American College of Cardiology Prevention of Cardiovascular Disease Council with mentorship from the Council’s Chair Dr. Eugene Yang (University of Washington Medical Center) who provides a message at the end of the episode.
First, Dr. Amit Goyal and Council Representative Dr. Mahmoud Al Rifai (FIT, Baylor College of Medicine) discuss the implications of the ADAPTABLE Trial with Dr. Gina Lundberg (Emory University School of Medicine).
Then Dr. Tommy Das (FIT, Cleveland Clinic), Dr. Rick Ferraro (FIT, Johns Hopkins) and Council Representative Dr. Anum Saeed (FIT, University of Pittsburgh Medical Center) discuss the results of the STRENGTH trial’s secondary analysis with Dr. Steven Nissen (Cleveland Clinic).
Disclosures: Dr Nissen reported grants from AstraZeneca during the conduct of the STRENGTH trial
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Show notes
ADAPTABLE Trial
The ADAPTABLE trial is a randomized open label pragmatic trial comparing two doses of aspirin (325 mg vs. 81 mg) for the secondary prevention of cardiovascular disease. The trial employed a range of innovative and low-cost methods to simplify the identification, recruitment, and follow-up of patients. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety outcome was hospitalization for major bleeding.
A total of 15,076 patients were followed for a median of 26.2 months. The primary effectiveness and safety outcomes were not significantly different between the two groups. Together with Dr. Lundberg we discuss design and methodological issues related to the trial and applicability to clinical practice.
ASA 81 mg is as effective as ASA 325 mg for reducing cardiovascular events ASA 325 mg does not cause more bleeding episodes than ASA 81 mg ASA dosing should be based on a clinician-patient risk discussion incorporating patients’ risk profile and their values and preferences Future trials should ensure adequate representation of women and race/ethnic minorities
The results of the present trial suggest that either dose of ASA (81 mg or 325 mg) would be adequate to lower patients’ risk of death or atherosclerotic cardiovascular events with similar risk of bleeding. ASA dosing should be based on patient values and preferences and clinician judgement as the effectiveness and safety profile of these two regiments appears to be equivalent on the basis of the present trial.
STRENGTH Trial, Secondary Analysis
Whether omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) reduce cardiovascular risk has been long debated. Data have largely remained inconclusive with several previous trials, particularly the VITAL and ASCEND, showing no significant cardiovascular benefit DHA and EPA supplementation. However, the REDUCE-IT and the JELIS trials showed cardiovascular benefit with higher dose of purified EPA compared to placebo. Meanwhile, the STRENGTH trial did not show any difference in CVD outcomes in treatment groups using a combined EPA/DHA formulation.
In this episode, we discuss a secondary anaylsis from the STRENGTH trial entitled “Association Between Achieved ω-3 Fatty Acid Levels and Major Adverse Cardiovascular Outcomes in Patients With High Cardiovascular Risk” presented at the ACC 2021 addressing the effects of carboxylic acid formulation of EPA/DHA (omega-3 CA) compared with placebo among patients with dyslipidemia and high cardiovascular risk.
This analysis showed that there was no added clinical benefit or harm i...
135. Narratives in Cardiology: Underrepresentation in Clinical Trials & Guidelines with Dr. Clyde Yancy – Illinois Chapter
Jul 12, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Victoria Thomas (Cardionerds Ambassador, Vanderbilt University Medical Center), and Dr. Quentin Youmans, cardiology fellow at Northwestern Medicine Bluhm Cardiovascular Institute, join Dr. Clyde Yancy, Vice Dean for Diversity and Inclusion and Chief of Cardiology in the Department of Medicine at Northwestern for an important discussion about underrepresentation in clinical trials and guidelines. This episode was recorded during a live event hosted by the ACC Illinois Chapter. Listen in to hear why diversity matters in clinical trials, how we can recruit more minorities in representation in CV trials and so much more! Stay tuned for a message by chapter Governor, Dr. Annabelle Volgman.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Audio editing by CardioNerds Academy Intern, Dr. Gurleen Kaur.
Video Version • Notes • References • Production Team
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Video version
https://youtu.be/5gGqWysdCT0
Show notes
1. Why does diversity matter in clinical trials?
Having clinical trial enrollment being representative of the general population in which we practice is essential for the generalizability of the trial results.Representative populations matter so we can say to patients, “yes, there were patients that think like you and look like you in the trial.” We can confidently tell them how patients within the trial have done. This is important when we are trying to narrow health disparities to provide confidence and comfort to our patients.Advocacy for health equity is important but not enough. We need data or evidence to support why a change in our behaviors and clinical practice is needed. An evidence base that reflects and includes all our patients is key to bridging health disparities.In medicine, the case for diversity also includes to better serve diverse patients, to promote health equity, to provide diverse mentors at all levels, to bring different points of view to debates and problem solving, to better engage our communities, and to include investigators with a broad range of perspectives in their scholarly activities. (1)
2. How do we recruit more minorities in representation in cardiovascular trials?
We need more advocates for diversity in trials in the room when the conversations about trial designs are being made. This is why diversity of leadership is important.There needs to be an intentional approach for every clinical trial to recruit people that are likely to be candidates for enrollment.Stop asking patients to come “downtown” but instead go to their town or their communities. Meet them where they are.Always make sure you are providing some additional advantage or opportunity for the patients you have recruited into your trials. Don’t make it a one-way street. Allow patients to feel that they are getting the best care and generate trust with them.To gain trust, try to get a sense of what is happening in your patient’s life. Find 2-3 minutes to ask them to give a mini biography of their lives.
134. Nuclear and Multimodality Imaging: Cardiac Sarcoidosis
Jul 05, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of cardiac sarcoidosis. Show notes created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
Cardiac sarcoidosis is a leading cause of morbidity and mortality for patients with sarcoidosis. A high index of suspicion is needed for the diagnosis as it is often recognized late or unrecognized. It is difficult to diagnose given the focal nature of the cardiac involvement limiting the utility of biopsy and the available clinical criteria have limited diagnostic accuracy. Multimodality imaging plays a large role in the diagnosis and management of patients with cardiac sarcoidosis with the different imaging modalities offering complimentary information and functions.
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Quoatables
“It’s not important for you to love the Soviet Union. It’s important for the Soviet Union to love you back [Stalin regarding the famous dissonant Russian poet Anna Akhmatova]. When we talk about PET, you love PET, but the PET has to love you back, and it has to love you back in a way where you have to know how to approach this test. With, first, some humility about its limitations: 1) inflammation is universal...and 2) the prep is extremely important.” -- 11:25
“A test without a good preparation is a preparation to fail.” --15:30
“Sarcoidosis is kind of the tuberculosis that we have in medicine—it can present as anything.” --36:40
Pearls
Cardiac Magnetic Resonance Imaging (Cardiac MRI) and/or 18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) are complimentary tests in the evaluation of cardiac sarcoidosis. Both tests look for scarring and inflammation. Cardiac MRI is a good initial test due to its high negative predictive value (i.e. absence of LGE makes cardiac sarcoidosis less likely) but not great for following a cardiac sarcoidosis patient’s response to therapy. Cardiac FDG-PET is great to follow a patient's response to therapy especially in patients with intracardiac devices such as a pacemaker.
18-fluorodeoxyglucose (FDG) is a glucose analog and just like glucose, is transported into the cell by transporters. Once in the cell, it is phosphorylated, like glucose is, by hexokinase in preparation for use in glycolysis. Unlike glucose, however, it does not proceed to be metabolized any further in the glycolysis pathway and remains trapped in the cell. In the inflammatory cells within sarcoid granulomas, glycolysis is significantly increased to fuel the large energy requirement. Thus, these inflammatory cells (i.e. macrophages) can take up large amounts of FDG.
When planning to obtain a cardiac FDG-PET for evaluation of cardiac sarcoidosis, patient preparation is key! There are several available dietary protocols to accomplish the goal of switching the patient’s metabolism to be reliant on fatty acids instead of glucose as an energy source. One such protocol used by the discussants in the episode is prolonged fasting (10-12 hours) prior to the study preceded by two meals that are high in fat and proteins and low in carbohydrates—a ketogenic diet. By having the patient eat this diet, we are trying to switch the metabolism because there is no ability or no offer ...
133. Case Report: Ventricular Arrhythmias & Heart Failure – A Shocking Diagnosis – University of Chicago
Jun 30, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), join cardiology fellows from the University of Chicago, (Dr. Mark Belkin, Dr. Ian Hackett, and Dr. Shirlene Obuobi) for an important discussion about case of a woman presenting with implantable cardioverter-defibrillator (ICD) discharges found to be in ventricular tachycardia (VT) storm and work through the differential of ventricular arrhythmias, etiologies of heart failure, and indications for permanent pacemaker and ICD placement. Advanced imaging modalities that aid in the diagnosis of cardiac sarcoidosis, manifestations and management of cardiac sarcoidosis are also discussed. Dr. Nitasha Sarswat and Dr. Amit Patel provide the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Leticia Helms.
Claim free CME just for enjoying this episode! Disclosures: Dr. Amit Patel disclosed ownership of small stocks in GE Healthcare Bio-Sciences.
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Case Media
Click to Enlarge
Episode Teaching
Pearls
The etiology of wide-complex tachycardias (WCT) of ventricular origin can be broken down by structurally normal versus structurally abnormal hearts. WCT in structurally normal hearts can be further broken down into idiopathic or primary arrhythmia syndromes. WCT in structurally abnormal hearts can be broken down into ischemic and non-ischemic etiologies.In patients with an unexplained non-ischemic cardiomyopathy, conduction abnormalities and/or ventricular arrhythmias should raise suspicion for cardiac sarcoidosis. Additional manifestations include atrial arrhythmias and pulmonary hypertension.Accurate diagnosis and treatment of cardiac sarcoidosis often requires multimodality cardiovascular imaging. Check out these terrific videos from Cardiac Imaging Agora: 1) PET for inflammation/sarcoidosis and 2) Echo and CMR for sarcoidosis.While a pathological tissue diagnosis is the gold-standard, endomyocardial biopsy has a low sensitivity, weven when paired with image guidance. Remember to consider extra-cardiac sites for biopsy.Decisions regarding ablation of ventricular arrhythmia or ICD placement should be done individually with careful assessment of active inflammation secondary to cardiac sarcoidosis and possible response to immunosuppressive medications.Management of cardiac sarcoidosis has two basic principles: 1) Treat the underlying process with immunosuppression and 2) Treat the cardiac sequelae: heart failure, conduction abnormalities, ventricular arrhythmias, atrial arrhythmias, and pulmonary hypertension.
Notes
1. The patient in this case was found to be in VT storm. Taking a step back, when we suspect a wide complex tachycardia (WCT) is VT, what are some etiologies we should keep in mind?
Differentiating between a supraventricular vs. ventricular origin of a WCT will be a topic for a future episode! But after you have determined that the origin of WCT is ventricular, considerations for the underlying etiology should include ischemia-related, non-ischemic cardiomyopathy-associated, primary arrhythmia syndromes and idiopathic (in addition to common considerations such as medications and electrolyte abnormalities)Chronic ischemia-related WCT is typically scar-mediated, a result of re-entrant mechanism and more commonly presenting as monomorphic VT. WCT in the setting of acute ischemia is likely a result of combination increased automaticity and re-entry, typically manifesting as polymorphic VT. In fact, acute ischemia is the most common cause of polymorphic VT, not Torsades de Pointes, and should be our first consideration. Torsades de Pointes specifically occurs due to an early afterdepolarization in a patient with an acqui...
132. Lipids: LDL Physiology & Function with Dr. Peter Toth
Jun 23, 2021
CardioNerds Academy Chief Fellows Dr. Rick Ferraro (FIT, Johns Hopkins) and Dr. Tommy Das (FIT, Cleveland Clinic) join Academy fellow Dr. Jessie Holtzman (soon, chief resident at UCSF internal medicine residency) to learn all about LDL physiology and function from Dr. Peter Toth!
Low-density lipoprotein cholesterol (LDL-C) has been well established as a risk factor for atherosclerotic cardiovascular disease with an ever growing armamentarium of medications to lower LDL-C plasma levels. Yet, LDL-C also plays a number of key physiologic roles across mammalian species, such as cell membrane formation, bile acid synthesis, and steroid hormone production. In this episode, we discuss the definitions of high, normal, low, and ultra-low LDL-C, what functional assays are used to measure LDL-C, and what is considered the safe lower-limit of LDL-C, if there is one at all. Drawing upon experience from rare genetic conditions including abetalipoproteinemia and loss-of-function variants of the PCSK9 gene, we glean pearls that clarify the risks and benefits of low LDL-C.
Relevant disclosure: Dr. Toth has served as a consultant to Amarin, Amgen, Kowa, Resverlogix, and Theravance; and has served on the Speakers Bureau for Amarin, Amgen, Esperion, and Novo Nordisk.
Pearls • Quotables • Notes • References • Guest Profiles • Production Team
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Pearls
1. Lipoproteins are processed via two major pathways in mammals: 1) exogenous fat metabolism that digests ingested lipids and 2) endogenous fat metabolism that synthesizes lipids in the liver and small intestine. High density lipoprotein (HDL)-mediated reverse transport also brings lipids from the periphery back to the liver.
2. LDL-C comprises ~70% of plasma cholesterol due to its long half-life of 2-3 days. It is one of 5 major lipid particles in plasma including chylomicrons, very low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), LDL, and HDL. The liver degrades 40-60% of LDL, while no other tissues in the body make up more than 10% of LDL. LDL-C is energy-poor and cholesterol rich, such that peripheral tissues may not utilize these particles as a fuel source.
3. Preserved functions of LDL-C across mammalian species include cell membrane formation, bile acid synthesis, and steroid hormone production. In other mammalian species, LDL-C levels are found in the 35-50 mg/dL range (Way lower than found in the general human population, and likely more representative of baseline human physiology!).
4. Large, randomized control trials do not consistently demonstrate major adverse effects associated with lower serum LDL-C levels, including risks of cognitive decline, hemorrhagic stroke, reduced bone density, or impaired immune function.
5. Initiation of, and education on LDL-lowering therapy remains insufficient, both in terms of long-term adherence to therapy and achieving current guideline directed goals of LDL-C <70mg/dL (And even lower in specific scenarios, such as repeat cardiovascular events).
Quotables
"It's pretty clear that this is an area where you can make a profound difference in the lives of people. It's very clear from the clinical trials that when we initiate therapies, whether it's lifestyle, through a statin, or an antihypertensive, you impact not only the quality of life, but the quantity of life. You make life better, you make life freer of disability, and you forestall death.”
“The bottom line is that LDL is spent garbage liquid and it is tantamount that the body be well-equipped to remove this LDL from the central circulation, because I will argue today that it is the single most important toxin that we produce.”
“If you ask what should a normal LDL be? Well, I'll tell you right now...
131. Narratives in Cardiology: Health Equity, Community Based Participatory Research, & Underrepresented Minority Women Physician-Scientists with Dr. LaPrincess Brewer
Jun 13, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) are joined by Dr. LaPrincess Brewer and Dr. Norrisa Haynes for a Narratives in Cardiology episode, with a special introduction by Dr. Sharonne Hayes. They discuss health inequities especially in communities of color, impact of projects utilizing community based participatory research (including FAITH! and SHARP founded by Dr. Brewer and Dr. Haynes respectively), and their experiences as underrepresented minority women physician-scientists.
This special discussion is brought to you in collaboration with the Association of Black Cardiologists (ABC). The ABC’s mission is to “Promote the Prevention and Treatment of Cardiovascular Disease, including Stroke, in Blacks and other Diverse Populations and to Achieve Health Equity for all through the Elimination of Disparities.” You may join and support the ABC at abcardio.org.
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Show notes for Health Equity, Community Based Participatory Research, & Underrepresented Minority Women Physician-Scientists
1. What healthcare disparities exist in communities of color?
The life expectancy of black Americans on average is 3.4 years shorter than that of white Americans. CVD is estimated to explain over 32% of the mortality difference between AA and white men and 43% of the difference between AA and white women. Together these conditions contributed to > 2 million years of life lost in the AA population between 1999-2010. (1)The impact of COVID-19 on minority communities has caused disproportionate morbidity and mortality and devastating health and financial hardship. According to the CDC, black Americans are 1.9x as likely as whites to die from COVID-19. (2) Additionally, at the beginning of the pandemic, a staggering 41% of black owned businesses closed due to COVID-19 as compared to 17% of white owned businesses. (3)
2. Community engagement & Community based participatory research (CBPR) - what is it?
CBPR often has a public health bend that focuses on and attempts to address social, structural and environmental inequities through active involvement of community members in all aspects of the research process (from conception to implementation). Community partners provide their unique expertise to enhance understanding of the community and facilitate implementation. (4)
3. What is FAITH!?
The Fostering African American Improvement in Total Health (FAITH) program was started by the phenomenal Dr. LaPrincess Brewer. FAITH is a cardiovascular health and wellness program that uses a CBPR approach to promote heart health in the African American faith-based community.Participants in the FAITH program have shown significant improvement in heart health knowledge. Participants have also had improvement in key heart disease risk factors such as blood pressure. The FAITH app was created in collaboration with community members to achieve easy access and easy usability. It provides vital information and a community network that provides support and motivation for participants.
4. Specifics of SHARP?
SHARP stands for Safe Haircuts as We Reopen Philadelphia. SHARP was started to assist local barbershops and salons implement proper COVID-19 safety practices to keep their businesses, clients, and staff safe. In partnership with community members, a safety blueprint was created to meet CDC and Philadelphia Health Department guidelines. Through donations from UPenn and Accenture, SHARP was able to distribute a significant number of PPE items to 30 businesses in West and Southwest Philadelphia. Additionally, due to the financial toll that the pandemic has had on small businesses, SHARP organized grant writing sessions through the Netter Center at Penn to...
130. Case Report: A Nagging Cough Post PCI – Indiana University
Jun 07, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), join cardiology fellows from Indiana University cardiology fellows (Dr. Asad Torabi, Dr. Michelle Morris, and Dr. Sujoy Phookan) to discuss a case of a patient who developed a nagging cough post PCI and is ultimately diagnosed with Dressler Syndrome. This case describes the work up and management of post infarct pericarditis and briefly reviews the dilemma of utilizing triple anti-thrombotic therapy with high dose aspirin in the post myocardial infarction period. Indiana University faculty and expert, Dr. Julie Clary provides the E-CPR for this episode.
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Patient Summary
A 56-year-old man with recent anterior STEMI and new heart failure with reduced ejection fraction presented with fevers, persistent cough, and pleuritic chest pain following percutaneous coronary intervention for the past two weeks. He was ultimately found to have post cardiac injury syndrome - post infarct pericarditis (formerly known as Dressler syndrome) with elevated inflammatory markers, a small pericardial effusion, and incidentally noted to have an apical left ventricular thrombus. This case describes the work up and management of post infarct pericarditis and briefly reviews the dilemma of utilizing triple anti-thrombotic therapy with high dose aspirin in the post myocardial infarction period.
Case Media
CXREKGClick to Enlarge
Episode Teaching
Pearls
1. Post cardiac injury syndrome (PCIS) following myocardial infarction can be very debilitating and recurrence is the concern when treatment is not pursued.
2. Acute pericarditis is a clinical diagnosis which does not require imaging and can have a wide spectrum on presentation ranging from fever/cough to the classic positional chest pain.
3. PCIS following myocardial infarction is less common in the post PCI era but we are starting to see more cases in late presenters.
4. We have good level of evidence to suggest the use of colchicine to reduce the recurrence of PCIS. COPPS and COPPS-2, are two such randomized placebo control trials, which show benefit in the cardiac surgical patient.
5. While triple therapy on high dose aspirin is not discussed in the 2013 ACCF/AHA STEMI guidelines, carefully assess your patient’s bleeding risk and invoke patient shared decision making whenever possible.
Notes
1. What is Post-Cardiac Injury Syndrome (PCIS) and what are the clinical manifestations?
PCIS is an umbrella term for specific clinical scenarios which may result in symptomatic acute pericarditis.PCIS encompasses:Post-myocardial infarction pericarditis which may be early or late (Dressler syndrome – the focus of this case)Post-pericardiotomy syndrome (PPS)Post-traumatic pericarditis including traumatic and iatrogenic (following most percutaneous procedures such as ablations, PCI, lead placement, etc).
2. How is PCIS (or post infarct pericarditis) diagnosed?
This is a clinical diagnosis, made when ≥ 2 of the following are present:Fever without alternative causePericarditic or pleuritic chest painFriction rubPericardial effusionPleural effusion with elevated CRPNote this is different from the diagnostic criteria for other causes of acute pericarditis which requires 2 of the 4 following features:Pericarditic chest painFriction rubNew widespread ST-elevations or PR depressions on ECGPericardial effusion (new or worsening)Supporting findings for pericarditis include:Elevation of inflammatory markers (CRP, ESR, WBC)Pericardial inflammation on cross sectional cardiac imaging (CT, CMR)
3. What are the complications of not treating Dressl...
129. Narratives in Cardiology: Celebrating LatinX Representation in Cardiology with Dr. Fidencio Saldana – Massachusetts Chapter
Jun 01, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Pablo Sanchez (CardioNerds Ambassador, Stanford University Medical Center), Dr. Maria Pabon (CardioNerds Ambassador, Brigham and Women’s Hospital), and Karen Malacon (Student doctor and LMSA co-chair at Stanford University Medical Center) join Dean for Students at Harvard Medical School, Dr. Fidencio Saldana, for an important discussion about Latinx representation in cardiology. We established the multifaceted benefits of diversity in healthcare, including improving access, cultural competency, and quality of care delivered. We also talked about the need to increase the number of underrepresented minority students in medicine in addition to the importance of removing barriers to improve education. By providing appropriate resources as well as early mentorship and exposure to the medical field, we can address the "leaky pipeline," or as Dr. Saldana reframed it, "the clogged pipeline.” Then, we dove into Dr. Saldana’s experiences in medical school, the barriers he overcame, and how his parents’ hard work and generosity motivated him to become the cardiologist he is now. This event hosted the ACC Massachusetts Chapter. Stay tuned for a message by chapter Governor Dr. Malissa Wood.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
Audio editing by CardioNerds Academy Intern, Dr. Gurleen Kaur.
Video Version • Quotables • Notes • References • Production Team
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Video version
https://www.youtube.com/watch?v=cpq2wVgG8mA
Quotable
We strive to ensure that we have a diverse set of college students and a diverse set of medical students and residents and fellows. But I think it's also just as important to ensure that we have the resources to ensure that those individuals that we've recruited and have done so hard to recruit, continue to succeed.
I've realized that you can teach mentoring, you can teach advising. And I think it's important to be able to create that culture and expectation. Some people may be a little bit better at it than others, but I think it's important to place an emphasis on that at each level of training, so that you can train to be a better mentor and a better advisor.
Show Notes
1. How is the LatinX representation in medicine compared to in the general population?
Based on the most recent data from the US census Bureau, as of 2019, the Hispanic proportion of the US population is about 18.5%.A recent report by the AAMC showed that for the academic year 2020-21, of around 22,000 medical school matriculants, only 11% were from LatinX background, although this number was higher compared to 2017 where only 9.8% of the matriculants were of LatinX origin.
2. How does increasing workforce diversity improve quality of care?
Cultural competency forms an important cornerstone of high-quality and equitable care for a diverse population, and it is learned not by lecture but by exposure, experience, and atmosphere.Medicine involves not only knowledge but meaningful connection and having a physician with a common background enhances the patient-doctor interaction by a spectrum of constructive effects.
128. Cardio-Obstetrics: Hypertensive Disorders of Pregnancy with Dr. Jennifer Lewey
May 28, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, and episode lead and Columbia University Cardiology Fellow Dr. Ersilia DeFilippis discuss hypertensive disorders of pregnancy (HDP) with Dr. Jennifer Lewey from the University of Pennsylvania.
In this episode, we cover chronic hypertension, gestational hypertension, and pre-eclampsia—all of which encompass HDP and complicate approximately 5-10% of all pregnancies. We also review risk factors for HDP, diagnostic criteria, peripartum and postpartum management, and much more! Be sure to tune in to hear Dr. Lewey discuss the future impact of HDP on cardiovascular disease for women later in life and strategies that can help improve care.
Finally Dr. DeFilippis shares her perspectives from her ACC.org FIT Section article titled “Shattering the Glass” including strategies to shattering the glass and tackling imposter syndrome in improving the representation of women in medicine.
Audio editing by CardioNerds Academy Intern, Leticia Helms.
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Pearls • Quotables • Notes • References • Guest Profiles • Production Team
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Pearls
To make a diagnosis of HDP, blood pressure should be measured on at least 2 occasions at least 4 hours apart.Hypertension diagnosed before 20 weeks gestation is considered chronic hypertension whereas hypertension after 20 weeks is categorized as gestational hypertension.Always check for warning signs for pre-eclampsia!One of the key treatments for pre-eclampsia is delivery but pre-eclampsia can occur still in the postpartum period.Aspirin use in pregnancy during second and third trimesters can reduce the risk of pre-eclampsia among women at risk.
Quotables
“Ideally a lot of these conditions come down to prevention and addressing potential cardio-obstetrics issues before they reach the cardio-obstetrics specialist.”
“Blood pressure can continue to be elevated even after delivery.”
“Pregnancy complications not only increase cardiovascular risk in the middle age population but also in the postmenopausal population.”
“Women feel so relieved when they know that their care team is dedicated to taking care of women with cardiovascular disease when they are pregnant.”
Show notes
Why should CardionNrds learn and know about hypertensive disorders of pregnancy?
Hypertensive disorders of pregnancy (HDP) complicate about 5-10% of all pregnancies. HDP is a term that encompasses chronic hypertension, gestational hypertension, pre-eclampsia, and pre-eclampsia superimposed on chronic hypertension. Women with history of HDP are at increased risk for stroke, ischemic heart disease, and cardiovascular death later in life. It is important to include obstetric history as part of our assessment of cardiovascular risk.
This obstetric history should include the number of pregnancies, history of gestational diabetes, gestational hypertension, history of pre-eclampsia as well as history of pre-term birth.
Following delivery, these women need close monitoring for development of chronic hypertension as well as primary prevention of cardiovascular disease.
2. How is gestational hypertension distinguished from chronic hypertension?
The key factor in distinguishing gestational hypertension from chronic hypertension is the timing of diagnosis. Before 20 weeks gestation, elevated blood pressure (defined as a reading > 140/90 on two occasions at least 4 hours apart) is considered chronic hypertension. After 20 weeks gestation, elevated blood pressures signify a pregnancy-induced process, namely gestational hypertension or pre-eclampsia if blood pressure elevati...
127. A Family Touched by Vascular Ehlers Danlos Syndrome: The Life & Legacy of Lizzie Gasser
May 24, 2021
In the last episode, episode 126, we discussed pregnancy and aortic disorders as part of The CardioNerds Cardio-obstetrics Series. This episode brought to mind episode 76, where our colleagues from the Cleveland Clinic taught us about a woman named Lizzie Gasser, who at the young age of 27 tragically presented with postpartum pulmonary edema, found to have papillary muscle rupture, and was ultimately diagnosed with Vascular Ehlers Danlos Syndrome (VEDS) at autopsy. This case has been published in JACC Case Reports: CardioNerds Corner.
Now, in this very special episode, we meet Lizzie Gasser, beyond her heart disease through the eyes of her loving husband, Todd Gasser. Her legacy underscores the importance of seeing our patients as people beyond their illness, in the context of their lives, values, and loved ones. This powerful discussion is led by Dr. Erika Hutt (cardiology fellow at the Cleveland Clinic) and Dr. Eunice Dugan, (internal medicine resident at Johns Hopkins Hospital). Dr. Harry “Hal” Dietz (professor of pediatrics, an associate professor of medicine and an assistant professor of neurological surgery at the Johns Hopkins University School of Medicine and a leading authority on genetic aortopathies (including Loeys-Dietz Syndrome which carries his name).
Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
This episode is brought to you in collaboration with the VEDS Movement. The VEDS Movement’s mission is to save lives and improve the quality of life of individuals with Vascular Ehlers-Danlos Syndrome (VEDS). By pursuing the most innovative research, educating the medical community, general public and affected individuals, and providing support to patients, families, and caregivers, The VEDS Movement, which is a division of The Marfan Foundation, charges forward and improves the outcomes for those living with VEDS. Individuals affected with VEDS can access medical webinars presented by the experts, join support groups, get involved in events and research, and donate by visiting TheVEDSMovement.org. Providers can also find resources, including CME opportunities, at TheVEDSMovement.org.
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Photos & Youtube videos featuring Lizzie Gasser and her family
https://www.youtube.com/watch?v=W4sVuctrUZs&t=1s
Video from the VEDS movement that Lizzie's family is interviewed in. Their interview is from 7m30s - 17m16s
https://www.youtube.com/watch?v=6CeXYnZHhbg
Video of Lizzy's life life that a friend put together.
Episode Guests
Dr. Erika HuttDr. Eunice DuganDr. Harry “Hal” Dietz
CardioNerds Case Report Production Team
Karan Desai, MDAmit Goyal, MDDaniel Ambinder, MD
126. Cardio-Obstetrics: Pregnancy and Aortic Disorders with Dr. Nupoor Narula
May 19, 2021
CardioNerd Amit Goyal, Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, and episode lead and Johns Hopkins University Cardiology Fellow, Dr. Anum Minhas, discuss pregnancy and aortic disorders with Dr. Nupoor Narula of Weill Cornell Medical College. Special introduction by Sukrit Narula.
In this episode we discuss the presentation and management of aortopathies during pregnancy. We begin by examining the pathophysiology of aortic disease during pregnancy, followed by a review of the heritable aortopathies and their risk of dissection. We then discuss preconception evaluation and antepartum care of women with aortopathies. We end with addressing management at the time of labor and delivery.
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Episode Abstract - Pregnancy and Aortic Disorders
In this episode we discuss the presentation and management of aortopathies during pregnancy. We begin by examining the pathophysiology of aortic disease during pregnancy, followed by a review of the heritable aortopathies and their risk of dissection. We then discuss preconception evaluation and antepartum care of women with aortopathies. We end with addressing management at the time of labor and delivery.
Pearls - Pregnancy and Aortic Disorders
1. Assessment of aortic root and ascending aortic measurements should be performed prior to conception in women with known aortopathies, connective tissue diseases with high risk for aortopathies, bicuspid aortic valve or familial thoracic aortic syndromes. Dimensions should always be verified with multi-modality imaging prior to decision-making.
2. It is important to recognize that the immediate postpartum period is a high risk period for aortic dissection in women with aortopathies.
3. Goal systolic blood pressure is < 120 mmHg and diastolic blood pressure is < 80 mmHg in women with aortopathies. This goal should be discussed with the patient's obstetric provider during pregnancy, however, to ensure a blood pressure target is chosen that is appropriate for optimal maternal and fetal outcomes. Beta-blockers followed by calcium channel blockers should be used for these targets. Aldosterone receptor antagonists are contraindicated during pregnancy.
4. Per the 2018 ESC guidelines, during pregnancy, women with aortic pathology should have an echocardiogram performed every 12 weeks if low risk, and every month (4 weeks) if high risk.
5. Women with type A dissection during pregnancy should be evaluated for urgent Caesarean section and aortic surgery if the fetus is viable. Women with a stable type B dissection may be managed medically if stable. All decisions should be made in a multidisciplinary fashion with consultation with Maternal Fetal Medicine and Cardiothoracic Surgery.
Quotables - Pregnancy and Aortic Disorders
1. “First and foremost, we must verify our dimensions. I'll say that again. We must verify our dimensions because nothing could have greater impact.”
2. “You know, our most important role is to provide transparency in pre-pregnancy risk counseling. We have to present the data that are available. We need to present the gaps in literature. We need to present the possibility that in the right individual, we can proceed through pregnancy safely with close clinical and imaging monitoring and follow up in a multidisciplinary construct.
Show notes - Pregnancy and Aortic Disorders
What is the risk of aortic dissection during pregnancy in Marfan syndrome?Women who undergo pregnancy with prepartum counseling and close clinical and imaging follow-up usually maintain stability of...
125. Case Report: Pressured to Diagnose A Young Woman with Syncope – University of Minnesota
May 13, 2021
CardioNerds (Amit Goyal & Karan Desai) join University of Minnesota fellows, Dr. Julie Power, Dr. Sasha Prisco, and Dr. Abdisamad Ibrahim for a riveting discussion in which they were pressured to diagnose a young woman with syncope. The fellows expertly take us through the next steps in the differential diagnosis, and management of pulmonary hypertension in this young patient! University of Minnesota faculty and expert in right ventricular (RV) failure in pulmonary arterial hypertension (PAH) Dr. Kurt Prins provides the E-CPR for this episode.
With this episode, the CardioNerds family warmly welcomes The University of Minnesota to the CardioNerds Healy Honor Roll. The CardioNerds Healy Honor Roll programs support and foster the the CardioNerds spirit and mission of democratizing cardiovascular education. Healy Honor Roll programs nominate fellows from their program who are highly motivated and are passionate about medical education. The University of Minnesota fellowship program director, Dr. Jane Chen has nominated Dr. Julie Power for this position. In addition to being a CardioNerds Ambassador, Julie has already done amazing CardioNerds work as part of the CardioNerds Academy fellowship.
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Patient Summary- Syncope and Pulmonary Hypertension
A Somali woman in her mid-30s with no significant past medical history presented with shortness of breath and exertional syncope. EKG revealed evidence of RV strain. CTA-PE protocol did not show PE. However, there was RV dilation and subsequent echocardiogram demonstrated normal LV, but moderately reduced RV function with evidence of RV pressure and volume overload. RVSP was estimated to be 188 mmHg!
Case Media
ABCDEFGHClick to Enlarge
A. CXR, B. ECG, C. PA measurements: Main PA measures 2.4 cm, right PA measures 2.3 cm, left PA measures 1.9 cm, D. Tricuspid valve Doppler, E. RA tracing, F. RV tracing, G. PA tracing, H. Wedge tracing
CTA PE: No PE, markedly dilated pulmonary trunk at 4.7 cm. Right main pulmonary artery measures 3.1 cm.
TTE: Parasternal long axis: Moderate right ventricular dilation compressing left ventricle. Global right ventricular function is moderately reduced.
TTE: Parasternal long axis- RV view: Right ventricular dilation with mild pulmonary regurgitation
TTE: Mild pulmonary regurgitation with dilation of main PA
TTE: Paradoxical septal motion consistent with right ventricular pressure and volume overload.
TTE: Apical 4 chamberParadoxical septal motion consistent with right ventricular pressure and volume overload. Moderate right ventricular dilation.Global right ventricular function is moderately reduced.Severe right atrial enlargement.
Paradoxical septal motion consistent with right ventricular pressure and volume overload.Moderate right ventricular dilation.Global right ventricular function is moderately reduced.Severe right atrial enlargement.Moderate to severe tricuspid regurgitation.
TTE: Positive bubble study
Episode Teaching
Pearls
Pulmonary hypertension (PH) can generally be categorized as pre-, post-, or combined pre- and post-capillary PH. Isolated pre-capillary pulmonary hypertension is characterized by: mean pulmonary artery pressure (mPAP) ≥ 20 mmHg, a pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg, and a pulmonary vascular resistance (PVR) ≥ 3 Woods units (WU). Pulmonary arterial hypertension (PAH) (WHO Group 1) falls under pre-capillary pulmonary hypertension.Schistosomiasis is the most common cause of PAH (WHO Group I) worldwide. Approximately 7% of patient with hepatosplenic ...
124. Cardio-Obstetrics: Pregnancy and Pulmonary Hypertension with Dr. Candice Silversides
May 09, 2021
CardioNerd (Amit Goyal), cardioobstetrics series co-chair Dr. Sonia Shah (FIT, UT Southwestern) and episode lead Dr. Kayle Shapero (FIT, UPMC) discuss pregnancy in patients with pulmonary hypertension with Dr. Candice Silversides, Associate Professor of Medicine and the Director of the Pregnancy and Heart Disease program and head of the Obstetric Medicine program at the University of Toronto.
Disclosures: None
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Abstract • Pearls • Quotables • Notes • References • Guest Profiles • Production Team
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Episode Abstract
In this episode we discuss the important and challenging topic of pulmonary hypertension in pregnancy. We’ll start by discussing the prevalence of pulmonary hypertension in pregnancy, as well as the associated maternal morbidity and mortality associated with each WHO class. We will use a case to help us illustrate the appropriate workup for pulmonary hypertension patients and to help us broach the challenging topic of pregnancy termination. In this case we will further explore advanced management options including pulmonary vasodilators, anti-coagulation, and the use of mechanical support. Don’t miss this opportunity to hear Dr. Silversides’ share her wisdom on the importance of a multidisciplinary care team to plan both the delivery as well as post-partum care to help prevent adverse outcomes for both the mother and baby.
Pearls
Pregnancy in pulmonary hypertension, regardless of the class, is considered high risk. Even women who appear hemodynamically stable at baseline can easily decompensate in pregnancy, and thus the overall mortality and morbidity are very high.Due to the high risk of maternal morbidity and mortality during pregnancy for women with pulmonary arterial hypertension, the option of termination of pregnancy should be discussed. Multidisciplinary care teams are the key to achieving optimal pregnancy outcomes in these patients. It is critical to create a team of experts with experience in pulmonary hypertension and plan for constant communication over the course of pregnancy.Pulmonary vasodilators including CCBs, phosphodiesterase inhibitors, and prostacyclin analogues should be initiated early to mitigate adverse outcomes.The majority of the complications in pulmonary hypertension patients occur after delivery, and so having a clear and safe postpartum plan is critical to a positive outcome.
Quotables
“We will someday identify the women who maternal morbidity and mortality is perhaps lower and we'll be able to give a better, risk assessment. But we're not quite there yet. And so currently, any woman who has pulmonary hypertension, true pulmonary hypertension in particular, pulmonary arterial hypertension, should be advised to avoid pregnancy.“ – Dr. Silversides“Women with PH can be falsely reassuring because they can walk in and look pretty good. And they're young, you know, they're not like the normal 70-year-old you might see on the ward. And so, you think they're going to be okay, but they can spiral downward very quickly. So I do think you also have to have a very high, um, uh, level of. Uh, caution in these patients.“- Dr. Silversides on assessing PH patients in pregnancy “I would tell you that I still think honesty is the best policy. I think you should offer women as much information as we currently know, so they can make informed decisions that are right for them. I think you also do have to really be sensitive to how you're delivering this information, because remember (for) some women it will have never occurred to them that they can't have a pregnancy. They may have been planning on having a kids and family and this information can really derail them.
123. Cardio-Obstetrics: Pregnancy and Arrhythmia with Dr. Andrea Russo
May 04, 2021
CardioNerd (Amit Goyal), cardioobstetrics series co-chair Dr. Natalie Stokes, Cardionerds Duke University CardioNerds Ambassador and episode lead fellow, Dr. Kelly Arps, join Dr. Andrea Russo, Director of Electrophysiology and Arrhythmia Services at Cooper Medical School of Rowan University and immediate past president Heart Rhythm Society, for a discussion about pregnancy and arrhythmia. Stay tuned for a message from Dr. Sharonne Hayes about WomenHeart. Audio editing by Gurleen Kaur.
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Dr. Russo's disclosures: Johnson and Johnson, Medtronic, Inc., Boston Scientific Corporation, Kestra, Medilynx, Up-to-Date, and ABIM.
Abstract • Pearls Notes • References • Guest Profiles • Production Team
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Episode Abstract
Pregnant patients may have exacerbation of underlying arrhythmic syndromes or unmasking of previously undiagnosed arrhythmic syndromes. Management of atrial and ventricular tachyarrhythmias should proceed with increased urgency in pregnant patients due to risk of adverse hemodynamic events in the mother and fetus. Cardioversion of atrial and ventricular arrhythmias is safe in pregnancy. Preferred antiarrhythmic agents in pregnant patients include metoprolol, propranolol, verapamil, flecainide, propafenone, sotalol, procainamide, and lidocaine. Management of arrhythmias in pregnancy should include collaboration with obstetrics and maternal-fetal medicine teams.
Pearls
Pre-conception counseling is a shared decision making process; include obstetrics and maternal-fetal medicine colleagues in challenging cases.
Have a high sense of urgency for acute arrhythmias in pregnancy due to risk of impaired fetal perfusion. Goals of acute arrhythmic management should include rapid treatment while avoiding hypotension.
In scenarios when beta blockers are indicated, metoprolol and propranolol are first choice. Avoid atenolol as this drug has the highest risk of fetal bradycardia and intra-uterine growth retardation in the class.
Lidocaine or procainamide should be first line for ventricular arrhythmias in pregnancy. Amiodarone is potentially teratogenic and should not be used in pregnant patients unless all other options have been exhausted.
Show notes
1. What are the expected electrophysiologic changes associated with pregnancy?
Increase in resting heart rate which peaks in third trimesterPR shorteningECG axis shift leftward and upwardNon-specific ST and T wave changes
These changes, along with increased cardiac output and volume with increased stretch in all chambers, increase the risk of re-entrant arrhythmias in those who are predisposed.
↑ atrial volume -> ↑ stretch -> ↑ ectopy -> ↑ risk for re-entrant arrhythmias
2. What is the approach to pre-conception counseling for patients with known arrhythmias or arrhythmic syndromes?
Anticipate frequency and potential severity of adverse arrhythmic outcomes during pregnancy and post-partum periodConsider available options for rhythm control and anticoagulation therapy, as appropriate, during the pre-conception, pregnancy, and post-partum periodsConsider catheter ablation prior to pregnancy, particularly for curable arrhythmias such as Wolff-Parkinson-White (WPW) and AVNRT Offer genetic counseling about hereditary risk to fetus for inherited arrhythmias such as Brugada syndrome and Long QT syndrome
3. What is the management of SVT in pregnancy?
Consider the increased risk of tachyarrhythmias in pregnancy:
Typically benign arrhythmias can lead to more rapid decompensation in mother due to increased baseline cardiac output.
Typically benign arrhythmias can lead to rapid danger to the fetus due to maternal hypotension and shortened diastolic ...
122. Narratives in Cardiology: Diversity, Implicit Bias, and #BlackMenInMedicine with Dr. Quinn Capers IV
Apr 26, 2021
CardioNerd (Amit Goyal), Narratives in Cardiology FIT representative Dr. Zarina Sharalaya and Cleveland Clinic fellow Dr. Gregory Ogunnowo join Dr. Quinn Capers IV, UTSW as Professor of Medicine, Associate Dean of Faculty Diversity, and the inaugural Vice Chair of Diversity, Equity, and Inclusion in the Department of Internal Medicine, for an important and moving discussion about diversity, implicit bias, and #BlackMenInMedicine. Special thanks to Dr. Kimberly Manning for her introductory remarks for Dr. Capers. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian.
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CardioNerds Narratives in Cardiology
The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field.
Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc.
Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc).
Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on:
1) Faculty's content area of expertise2) Faculty's personal and professional narrative
As part of their narrative, faculty will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning.
To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert.
The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez.
Guest Profiles - Physician Scientists Women Electrophysiology
Dr. Quinn Capers, IV
Dr. Quinn Capers, IV grew up in Dayton Ohio and left his hometown to do his undergraduate training at Howard University. He began his journey in medicine at The Ohio State University and went on to do residency, cardiology fellowship, and interventional cardiology training at Emory University. After graduation he worked for 8 years in private practice, and made the switch back to academics and came back to Ohio State to continue his career.
In 2009, he was named associate dean of admissions and in 10 years, the College of Medicine went from 13% underrepresented minorities to 26% of the 2019 entering class, and in the last 6 years women have outnumbered men in the incoming classes. In 2019 he was promoted to Vice Dean for Faculty Affairs, received the award for professor of the year,
121. Case Report: Complex Shock in Shone Complex – University of Wisconsin-Madison
Apr 26, 2021
CardioNerds (Amit Goyal & Daniel Ambinder) join Dr. Rayan Jo Rachwan, Dr. Anupama Joseph, and Dr. Mohammed Merchant from the University of Wisconsin-Madison for a classic Madison dinner cruise! They discuss the following case: Mixed shock secondary to severe right ventricular outflow tract obstruction with Gemella Haemolysans prosthetic pulmonary valve endocarditis in a young patient with Shone Complex (syndrome). Dr. Ford Ballantyne III provides the E-CPR segment for this episode. Special introductory music composed by Dr. Rayan Jo Rachwan. We are excited to welcome University of Wisconsin- Madison to the CardioNerds Healy Honor Roll and Dr. Rayan Jo Rachwan as the CardioNerds Ambassador.
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Jump to: Patient summary - Case media - Case teaching - References
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Patient Summary
A 26-year-old male with history of bicuspid aortic valve and Shone Complex (syndrome)—status post coarctation repair, subaortic resection and Ross-Konno operation—presenting with 3 months of constitutional and respiratory symptoms. Initial evaluation demonstrated that patient was in a state of mixed shock due to a large pulmonary Melody valve thrombus with superimposed Gemella Haemolysans prosthetic valve endocarditis. He required treatment with inotropes, pressors, followed by intubation and extracorporeal membrane oxygenation (ECMO). Patient was treated initially via right heart catheterization with balloon dilation and stent placement to his right ventricle-to-pulmonary artery conduit, which lead to significant improvement in his hemodynamics. Patient was then decannulated from ECMO, extubated, weaned off pressor support and later underwent a successful surgical resection of the infected pulmonary homograft and Melody valve/stents and replacement with pulmonary-valved conduit. He was also discharged on a prolonged course of antibiotics.
Case Media - Shone Complex
A
B
C
D
Click to Enlarge
A. CXR, B. ECG, C. TV Doppler, D. PV Doppler
CTA Chest
•Melody pulmonic valve repair with large thrombus arising from the mid-distal valve extending into the main pulmonary artery and proximal left pulmonary artery. Evaluation for distal subsegmental pulmonary emboli is limited. •Tiny focus of air in the thrombus may be related to contrast injection. Infection is less likely. •Enlarged right heart chambers, may be in part chronic right heart enlargement and/or new right heart strain. No pulmonary infarct.
CT chest abdomen and pelvis with contrast
•Findings suggestive of acute hepatitis and acute pancreatitis. No pancreatic hypoenhancement or peripancreatic fluid collection. •No abscess within the abdomen or pelvis. •Small caliber of the infrarenal abdominal aorta and bilateral iliac arteries, probably congenital.
TTE 1
TTE 2
TTE 3
TTE 4
TTE 5
TTE 6
RHC with balloon dilation of the RV-PA conduit and evidence of multiple levels of stent fracture.
Pulmonary angiogram showing no evidence of distal embolization or significant pulmonary embolism and no evidence of perforation. There is evidence of moderate pulmonary insufficiency into a dilated right ventricle.
Episode Teaching - Shone Complex
Pearls
1. Patients with congenital heart disease are more predisposed to infective endocarditis (IE). Therefore, there should be a low-threshold for infectious workup in the case of unexplained fever or malaise without associated symptoms for >72 hours. Every routine visit should screen for symptoms and signs of IE.
2. Treatment of right ventricular (RV) outflow tract obstruction with balloon dilation +/- stenting can be considered as a bridge to valve replacement...
120. The Braunwald Chronicles: Triple Threats, Randomized Controlled Trials, Textbooks & Digital Education
Apr 25, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for this wonderful series, as we journey through the history of cardiology, across 6 extraordinary chapters. We complete The CardioNerds Braunwald Chronicles with Chapter 6 where Dr. Braunwald discusses triple threats, randomized controlled trials, textbooks & digital education. He reflects on the impact he has had through education through text books and how being an educator has been just as gratifying to him as being a scientist.
We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein.
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119. The Braunwald Chronicles: Carotid Sinus Stimulation, Limitation of Infarct Size & The Open Artery Hypothesis
Apr 23, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for this wonderful series, as we journey through the history of cardiology, across 6 extraordinary chapters. We continue with Chapter 5 where Dr. Braunwald discusses his discoveries related to carotid sinus stimulation, limitation of infarct size & the open artery hypothesis. The open artery hypothesis has revolutionized the way we take care of patients with myocardial infarction. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein.
Dr. Braunwald's favorite paper: (Please note the very last paragraph)Kjekshus JK. Factors influencing infarct size following coronary artery occlusion. JOslo City Hosp. 1974;24(11-12):155-175.
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118. The Braunwald Chronicles: A “Royal Screw-up” & The Discovery of Hypertrophic Cardiomyopathy
Apr 23, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters.
We continue with Chapter 4 where Dr. Braunwald discusses his discoveries related to the A "Royal Screw-up" & The Discovery of Hypertrophic Cardiomyopathy. There are hypertrophic cardiomyopathy centers of excellence sprinkled throughout the world. Comprehensive ACC/AHA guidelines for hypertrophic cardiomyopathy that came out in 2020, there's incredible drug discovery and randomized controlled trials looking at innovations in the management of HCM. We had a whole series on CardioNerds for hypertrophic cardiomyopathy where we taught about the four "Ps" or four preventions of hypertrophic cardiomyopathy management; prevent symptoms, prevent stroke in atrial fibrillation, prevent sudden cardiac death in the patient and prevent sudden cardiac death in the family. How fortunate are we to now hear all about how hypertrophic cardiomyopathy was discovered.
We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles.Audio editing by Pace Wetstein.
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117. The Braunwald Chronicles: Natural History of Aortic Stenosis, Beta-Blockers in Heart Failure & Seizing the Moment
Apr 22, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters.
We continue with Chapter 3 where Dr. Braunwald discusses his discoveries related to the natural history of aortic stenosis, beta-blockers in heart failure and times when seizing the moment led to important contributions to the world of cardiology. Dr. Braunwald also shares insights on mentorship as he speaks fondly of his relationship with the cardiac surgeon, Dr. Andrew "Glenn" Morrow. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles.
Audio editing by Pace Wetstein.
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116. The Braunwald Chronicles: The Camelot Years, Myocardial Oxygen Consumption & The Transseptal Approach
Apr 20, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters.
We continue with Chapter 2 where Dr. Braunwald discusses his Camelot years, discoveries with regards to myocardial oxygen consumption & how the transseptal approach was developed. We hear about the incredible environment at the NIH during his early days, his delineation of the variables that result in myocardial oxygen demand and the discovery of the transseptal approach, which is so key to so many of our percutaneous interventions today.
We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein.
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115. The Braunwald Chronicles: At The Right Place, At The Right Time & With The Right People
Apr 19, 2021
CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters. We begin with Chapter 1: At The Right Place, At The Right Time & With The Right People. We learn about how serendipitous events in Dr. Braunwald’s early days, paired with his incredible grit & brilliance got him to the NIH where he quickly became the chief of cardiology at the of age 31, the precipice to an illustrious career ahead. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. A very special thanks Dr. Randall Starling, advanced heart failure faculty at the Cleveland Clinic, former President of HFSA, and a dedicated mentor and support to CardioNerds for introducing us to Dr. Eugene Braunwald and for providing the following introduction. Audio editing by Pace Wetstein.
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114. Cardio-Obstetrics: Pregnancy and Coronary Disease with Dr. Malissa Wood
Apr 16, 2021
CardioNerds Amit Goya and Daniel Ambinder, cardioobstetrics series co-chair Dr. Natalie Stokes, and episode lead Dr. Priya Kothapalli (University of Texas at Austin, Dell Medical School) discuss pregnancy and coronary artery disease with Dr. Malissa Wood, co-founder and co-director of the Corrigan Woman’s Heart Health center at Massachusetts General Hospital. They discuss the differential diagnosis of chest pain in the pregnant patient, the diagnostic approach and management of acute coronary syndromes in the patient population, and manifestations and management of SCAD in pregnancy. Episode introduction by Dr. Julie Power.
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Guest Profiles • Production Team
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Guest Profiles - Episode 114. Pregnancy Coronary Disease
Dr. Malissa Wood
Dr. Malissa Wood is a cardiologist at MGH, where she is one of the founders and co-director of the Corrigan Woman’s Heart Health center at MGH. She has authored two books “Smart at Heart” and “Thinfluence” and she’s made substantial contributions globally in promoting awareness of gender disparities in cardiovascular disease. She is the incoming chair elect for the ACC board of governors and current Governor of the Massachusetts ACC chapter, and is one of the leading experts in the world of Spontaneous Coronary Artery Dissection, or SCAD.
Dr. Priya Kothapalli
Dr. Priya Kothapalli is a second-year cardiology fellow at The University of Texas at Austin, Dell Medical School. Her clinical interests include endothelial dysfunction and vulnerable plaque. She looks forward to advanced training in interventional cardiology.
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Natalie Stokes, MDSonia Shah, MDAmit Goyal, MDDaniel Ambinder, MD
113. Cardio-Obstetrics: Pregnancy, Heart Failure, and Peripartum Cardiomyopathy with Dr. Julie Damp
Apr 12, 2021
CardioNerds (Amit Goyal and Daniel Ambinder), cardioobstetrics series co-chair Dr. Natalie Stokes, Northwestern University CardioNerds Ambassador Dr. Loie Farina, and episode lead fellow, Dr. Agnes Koczo (University of Pittsburgh) join Dr. Julie Damp of Vanderbilt University Associate Director of the VUMC Cardiovascular Disease Fellowship for a discussion about pregnancy, heart failure, and peripartum cardiomyopathy. Episode introduction by Dr. Luis Calderon. Audio editing by Pace Wetstein.
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Abstract • Pearls • Quotables • Notes • References • Guest Profiles • Production Team
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Episode Abstract
In this episode we discuss the presentation of peripartum cardiomyopathy (PPCM), tips for examining a late antepartum patient, and review management of pregnancy complicated by cardiogenic shock. Weaved throughout the case, we discuss important concepts including the role of prolactin in PPCM which factors into both treatment decisions like prescribing bromocriptine (what!) as well as counseling on breastfeeding. Be sure to tune in to hear Dr. Damp’s review of the latest evidence regarding the diagnosis and management of PPCM, as well as her personal experience counseling patients on heart failure therapies and ICD placement in the context of important factors like breastfeeding status, contraception and future pregnancies.
Pearls
1) PPCM most typically presents in the early postpartum period and is defined as an LVEF <45% (with or without LV dilatation and RV involvement) and no other explanation for the cardiomyopathy.
2) Patients with PPCM can present with classic heart failure symptoms, which may be challenging to distinguish from the typical symptoms and signs of pregnancy. To help differentiate pathology from normal physiology, consider the constellation of exam findings (e.g., isolated peripheral edema versus peripheral edema, +S3, elevated JVD and rales), the severity of the findings, and comparison of symptoms/findings to prior pregnancies.. There are no specific serum markers for PPCM yet.
3) Prolactin and a vascular etiology have been implicated in the pathogenesis of PPCM. There are ongoing trials to evaluate treatment with bromocriptine, which blocks prolactin (look out for upcoming the REBIRTH RCT examining this!). Importantly, there is no clear evidence that breastfeeding is prohibitive to myocardial recovery and should not be discouraged given benefits to both mom and baby.
4) Many of these patients recover, but those at highest risk are those with severely depressed LV systolic function, dilated LVs, RV involvement, and of African descent.
5) Goal directed medical therapy with beta-blockers in both ante- and postpartum period is a cornerstone of therapy. ACEi/ARB/MRA/ARNI are contraindicated in pregnancy but may be added postpartum and with breastfeeding.
Quotables
1. “It can be so challenging to distinguish symptoms (in a pregnant patient) from cardiac disease! One thing to keep in mind is severity – the more pronounced a finding or symptoms, the more concerning.” - Dr. Julie Damp
2. ”We often have more options than we think in medical management for heart failure through pregnancy and breastfeeding, but they do need some adjustments from our usual therapies.” -Dr. Julie Damp
3. “Start discussions about prognosis, monitoring, future pregnancies, and contraception early!” -Dr. Julie Damp
Show notes
1. How do you distinguish findings of normal pregnancy from signs and symptoms of heart failure?
Pregnant patients may normally have basal rales that typically clear with coughing, laterally shifted PMI, bounding PMI and pulse, JVD, S3, systolic murmur, edema/tense soft tissue,
112. Narratives in Cardiology: Advocacy for Women’s Heart Health and Empowering Women in Cardiology with Dr. Gina Lundberg
Apr 05, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Gina Lundberg (Associate Professor of Medicine at Emory University School of Medicine, Clinical Director of the Emory Women's Heart Center, and Chair Elect for the ACC WIC Section) and Dr. Zarina Sharalaya (interventional cardiology fellow at CCF, CardioNerds Narratives FIT Council Member) for a Narratives in Cardiology episode. Dr. Lundberg highlights the disparities that exists with representation of women in cardiology and cardiology subspecialties, and how to navigate the challenges that exist for women in cardiology. Dr. Lundberg takes us through her career journey and gives several pearls for fellows-in-training regarding achieving career goals, networking, mentorship, and the use of social media to further your career. Special message from Dr. Annabelle Volgman. Audio editing and episode introduction by Gurleen Kaur.
Quotables • Show notes • Guest profiles • About Narratives in Cardiology • Production team
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Quotables
“Improving the work environment for women is going to be really important for job retention and for encouraging more women to go into EP, interventional cardiology, and heart failure...”
“One of the words of wisdom I say to a lot of early career women is slow down. You don't have to drink the whole thing in your first 10 years. You can just slowly ease into it- there's a time and a place for everything, a season for everything.”
“So start building your network. Build your ‘otter raft’ and by otter, I mean that group of people, men or women who really support you and lift you up, who might recommend you for a position or a lecture that might share opportunities with you”
Show notes
What are some strategies to improve female representation in cardiology?
Practicing cardiologists, both men and women, need to mentor and sponsor trainees to attract more female into the field.Improving the work environment is key to retention of women in cardiology (allowing for more flexibility to meet needs such as child-care etc.).We need to build the pipleline to start recruiting females early on, even in high school.
2. What are some strategies to network as a fellow-in-training?
Start building your network early - attend ACC and AHA meetings. The ACC Legislative Conference is great because it’s a bit smaller and allows for more opportunities to meet leaders in the ACC.Share your story with other people (example your old high school or sorority/fraternity) as an opportunity to mentor and inspire others.Build your “otter raft”… that group of people who really support you and lift you up, who might recommend you for a position or a lecture that might share opportunities with you.
3. What is the role or value of social media for professional development?
Social medial democratizes the landscape, giving everyone a voice regardless of level of training, background, or beliefs.It is invaluable for connecting and networking, on a global scale.It empowers individuals to share – be it powerful stories, their thoughts, and of course education.We of course need to be responsible with protecting our patient’s privacy, be discerning consumers, and be professional in our interactions.
CardioNerds Narratives in Cardiology
The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field.
Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race,
111. Cardio-Obstetrics: Normal Pregnancy Physiology with Dr. Garima Sharma
Mar 31, 2021
CardioNerd Amit Goyal, cardioobstetrics series co-chair Dr. Natalie Stokes, and episode lead Dr. Daniela Crousillat discuss normal cardiovascular physiology in pregnancy with Dr. Garima Sharma, Director of the Cardio-Obstetrics Program and the Ciccarone Center ‘s Associate Director of Preventive Cardiology Education in the Division of Cardiology. They discuss physiology from conception to post-partum, including the key hemodynamic, hormonal, and structural changes associated with normal pregnancy in the absence of pre-existing cardiovascular disease. Series introduction by Dr. Sharonne N. Hayes.
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Abstract • Pearls • Quotables • Notes • References • Guest Profiles • Production Team
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Episode Abstract
Join us for a thrilling ride with our expert as we dive into the normal cardiovascular physiology of women through pregnancy. We discuss physiology from conception to post-partum, including the key hemodynamic, hormonal, and structural changes associated with normal pregnancy in the absence of pre-existing cardiovascular disease. We discuss how these physiologic changes manifest the history, physical exam, and key diagnostic testing (ECG, laboratory markers, and echocardiogram). Armed with these basic principles, we join Dr. Garima Sharma on patient consults to learn about potential signs and symptoms of cardiovascular disease in pregnancy and appropriate ways to risk stratify women with pre-existing or acquired cardiovascular disease in pregnancy. Importantly, we delve deeper into the importance of the growing field of cardio-obstetrics in the context of rising maternal mortality and staggering racial disparities in the care and outcomes of women in pregnancy.
Pearls
In normal pregnancy, plasma volume increases by up to 50% resulting in an adaptive decrease in systemic vascular resistance (SVR) by 25% and an increase in cardiac output (CO) by ~50% by the 2nd trimester.Brisk carotid upstrokes, an S3 gallop, soft systolic ejection murmurs, pedal edema, and a mildly elevated jugular venous pressure (JVP) can all be normal physiologic findings in pregnancy in the context of no other signs/symptoms to suggest heart failure.A normal NT-proBNP among pregnant patients with pre-existing cardiovascular disease has a high negative predictive value for predicting adverse maternal cardiac outcomes.Pregnancy risk predictor tools (mWHO, CARPREG II, ZAHARA) are a crucial component of pre-conception counseling to help predict which women with existing cardiovascular disease are at highest risk for adverse maternal outcomes.The U.S. ranks 1st in the world for maternal mortality among developed nations and cardiovascular disease is the leading cause of pregnancy-associated mortality in the U.S. Non-Hispanic Black are 3.5 times more likely to die from pregnancy as compared to White women.
Quotables
“You don’t know where you are going until you know where you have been” - Dr. Garima Sharma on the importance of holding on to hope when encountering difficult situations in our training and career pathways.
“Do not fear the pregnant patient! The pregnant patient is going through a normal physiologic process in her life, and the more we are familiar with it, the less we fear it” - Dr. Garima Sharma on taking care of pregnant patients.
“If you are going to move the needle on maternal mortality and in making a long-term sustainable change in the lives of these women, you have to focus on prevention” - Dr. Garima Sharma on the importance of prevention in reducing maternal mortality.
“Be empathetic. For most women, pregnancy is a normal state. These women need your help!” - Dr. Garima Sharma on the importance of taking care of women in ...
110. Case Report: Feeling Dyspneic & Rejected – University of Maryland
Mar 25, 2021
CardioNerds (Amit Goyal and Karan Desai) enjoy a picnic at Charm City’s Inner Harbor with Dr. Manu Mysore, Dr. Shawn Samanta, and Dr. Rawan Amir from the University of Maryland division of Cardiology as they dive into important case discussion about a patient with of non-ischemic cardiomyopathy s/p orthotopic heart transplantation who presents with dyspnea due to cell mediated rejection. Dr. Gautam Ramani Medical Director of Clinical Advanced Heart Failure at the University of Maryland, provides the e-CPR segment.
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Patient Summary
A 58 year old woman with a history of non-ischemic cardiomyopathy s/p orthotopic heart transplantation in 2015 presented with worsening dyspnea upon exertion. Dyspnea in a post cardiac transplant brings forth a wide differential diagnosis spanning all the typical causes of dyspnea as well as causes more specific or common to the patient with a heart transplant. In this particular case, TTE showed newly reduced ejection fraction and valvular disease. Cell mediated rejection was considered highest on the differential and confirmed on endomyocardial biopsy. Given hemodynamic compromise with multiple foci of myocyte damage on biopsy, she was started on high dose steroids and anti-thymocyte globulin for treatment of rejection. Early identification and management of cell mediated rejection is crucial to the survival of patients like ours. Final diagnosis: orthotopic heart transplantation rejection.
Case Media - Orthotopic heart transplant rejection
Chest x-ray: Status post sternotomy. Patchy peripheral opacities in the bilateral lower lobes. Blunting of the costophrenic angles consistent with pleural effusion.
Sinus tachycardia, HR 111, RBBB, Sub millimeter STE in leads 1, aVL. STD in infero-posterior leads
TTE: Short axis
TTE: Long axis
TTE: Apical 4 Chamber
Coronary angiography: RCA
Coronary angiography: LAD/LCx
Episode Education
Pearls
New onset heart failure in a post cardiac transplant patient should raise concern for acute cardiac allograft rejection, as well as all the usual culprits in nontransplant patients.Younger African American women and those with elevated HLA mismatches are key risk factors for cell mediated rejection.Treatment for cell-mediated (i.e., T-Cell mediated) rejection includes steroids and antithymocyte immunoglobulin and regimens are based on the severity ofclinical and histologic features.Though infrequent as an initial presentation of acute cellular rejection, new onset arrhythmias in a post cardiac transplant patient should raise concern for rejection as a possible etiology. Reversal of rejection should be verified with endomyocardial biopsy following treatment for rejection. The timing and frequency of biopsy will likely depend upon whether corticosteroids and/or antithymocyte therapy was utilized.
Notes - Cell mediated rejection and more!
1) What are some common complications of cardiac transplantation?
Common complications following cardiac transplantation can be divided into two major categories: graft-related complications and non-graft-related complications.
Graft-related complications include:Early graft dysfunction (EGD) – reversible and irreversible injury related to organ procurement and reperfusion. Remember it is common for transplant patients to require inotropic and vasopressor support coming off cardiopulmonary bypass. Furthermore, LV diastolic dysfunction is also common after transplantation usually reflecting reversible ischemia or reperfusion injury and normally resolves over days to weeks,
109. Nuclear and Multimodality Imaging: Cardiac Amyloidosis
Mar 22, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of multimodality imaging evaluation for cardiac amyloidosis. Show notes were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
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Show Notes & Take Home Pearls - Nuclear and Multimodality Imaging: Cardiac Amyloidosis
Episode Abstract:
Previously thought to be a rare, terminal, and incurable condition in which only palliative therapies were available, multimodality imaging has improved our ability to diagnose cardiac amyloidosis earlier in its disease course. Coupled with advances in medical therapies this has greatly improved the prognosis and therapeutic options available to patients with cardiac amyloidosis. Multimodality imaging involving echocardiography with strain imaging, 99mTc-PYP Scan, and cardiac MRI can help diagnose cardiac amyloidosis earlier, monitor disease progression, and even potentially differentiate ATTR from AL cardiac amyloidosis.
Five Take Home Pearls
Cardiac amyloidosis results from the deposit of amyloid fibrils into the myocardial extracellular space. The precursor protein can either be from immunoglobulin light chain produced by clonal plasma cells (in the setting of plasma cell dyscrasias) or transthyretin (TTR) produced by the liver (which can be “wild type” ATTR caused by the deposition of normal TTR or a mutant ATTR which is hereditary). These represent AL Cardiac Amyloidosis and ATTR Cardiac Amyloidosis respectively.Remember that amyloidosis can affect all aspects of the heart:the coronaries, myocardium, valves, electrical system, and pericardium! Be suspicious in a patient with history of HTN who has unexpected decrease in the need for antihypertensive agents with age or presents with a lower-than-expected blood pressure.Multimodality imaging can assist with the diagnosis of cardiac amyloidosis in patients with a high clinical suspicion, monitor disease progression, and even potentially differentiate ATTR from AL cardiac amyloidosis.Strain imaging assessment of global longitudinal strain (GLS) in patients with amyloid may demonstrate relatively better longitudinal function in the apex compared to the base, termed “apical sparing” or “cherry on top” (though in advanced stages the base to apex strain difference tends to become smaller). This has a 93% sensitivity and 82% specificity in identifying patients with cardiac amyloidosis and is particularly helpful with differentiating true cardiac amyloidosis from “mimics” such as hypertrophic cardiomyopathy, aortic stenosis, or hypertensive heart disease.When the clinical suspicion for cardiac amyloidosis is high, a semiquantitative grade ≥ 2 (myocardial uptake ≥ bone) on 99mTc-PYP Scan combined with negative free light chain and immunofixation assays (to rule out AL cardiac amyloidosis) can diagnose ATTR cardiac amyloidosis and exclude AL cardiac amyloidosis w/ 100% PPV! Furthermore, this can circumvent the need for endomyocardial biopsy. Echocardiography and cardiac MRI (CMR) are helpful for building the clinical suspicion for cardiac amyloidosis.When there is suspicion for AL cardiac amyloidosis, tissue biopsy is mandatory.
Quotable: - Nuclear and Multimodality Imaging: Cardiac Amyloido...
108. Narratives in Cardiology: Physician Scientists & Women in Electrophysiology with Dr. Christine Albert and Dr. Rachita Navara
Mar 16, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Christine Albert (Professor of Medicine, Founding Chair of the Department of Cardiology at Cedars-Sinai, and President of Heart Rhythm Society) and Dr. Rachita Navara (FIT at Washington University, soon to be EP fellow at UCSF) for a Narratives in Cardiology episode. We learn from their experiences as physician scientists and women in cardiology, and specifically in electrophysiology.
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Show notes
1. Over the last several decades, what have we learned about the contribution of lifestyle factors to atrial fibrillation?
Particularly in women, the development of obesity (BMI > 30 kg/m2) is associated with a 41% increase in the risk of developing atrial fibrillation (AF). Even short-term weight gains are associated with a 18% increased risk of developing AF. Fortunately, losing weight could modify or even reverse this elevated risk [1]Exercise is beneficial for reducing the risk of AF, but higher frequency of vigorous exercise is actually associated with an increased risk of developing AF in young men and joggers. This risk decreases with age, and is offset by the other benefits of vigorous exercise on AF risk factors [2]The link between alcohol consumption and AF was first described in 2008: for healthy middle-aged women, consuming two or more alcoholic drinks is associated with a statistically increased risk of developing AF [3]The recent VITAL trial is the largest and longest randomized trial on primary prevention of AF, following over 25,000 men and women over five years. As recently presented at AHA 2020, Dr. Christine Albert and her study team found that neither vitamin D nor fish oil prevents the development of AF [4]
2. What is some practical advice on giving presentations and preparing research grants from Dr. Albert, renowned physician-scientist, and leader in electrophysiology?
Whenever possible, Dr. Albert recommends memorizing your presentation to avoid referencing notes frequently, and to allow for continued eye contact with the audience. Practice delivering your presentation multiple times prior to the scheduled talk.When preparing a grant, start early and seek feedback and edits from those in and out of your field.In many cases, a grant review involves individuals who may not be in your exact scientific field, so the priority is to interest the grant readers regardless of their scientific background.
3. Whether in research or clinical care, what are the common features of a well-oiled clinical team?
In an ideal team, every individual adds value and has a clear role. Team members show mutual respect and provide the autonomy for other team members to demonstrate their expertise.Don’t be intimidated by the individuals on your team who are extremely talented or experienced in a given domain – this in turn elevates you by being on the same team!Leaders are most successful when they enable others to succeed. The spirit of collaboration and respect comes from the top, so leaders need to demonstrate respect for every team member and give each person a role, eliminating the need for team members to compete with each other.
4. What is some advice for female trainees navigating a male-dominated field (e.g. electrophysiology)? What makes a good mentor and mentee?
It is very important to seek female or otherwise relatable role models in your field. While representation increases, it can also be valuable to seek female mentors outside your specific field.It is just as important for male mentors to continue to support female trainees, especially in fields where females are underrepresented.Often, as a mentee you may change your area of interest or seek a new area of specializ...
107. Case Report: A Rare Cause of Cardiogenic Shock – More than Meets the Eye – Thomas Jefferson University Hospital
Mar 15, 2021
Join Thomas Jefferson University FITs, Drs. Sean Dikdan, Rachel Debenham and Harsh Doshi, as well as Cardionerds, Dan Ambinder and Karan Desai, on this incredible story of a young man who presented with ventricular arrhythmias and cardiogenic shock. The TJU Cardionerds expertly walk us through a rare diagnosis, his course over several years and his ultimate treatment with heart transplantation. From the evaluation of cardiogenic shock to the role of endomyocardial biopsy to facing inequities in organ allocation, there are learning pearls for every listener!
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Episode Graphic by Dr. Carine Hamo
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Patient Summary
A 35 year old healthy male presents with cardiogenic shock and new heart failure with reduced ejection fraction. He has ventricular instability and is diagnosed with giant cell myocarditis by endomyocardial biopsy. His course over several years includes LVAD bridge to heart transplantation. He then has a recurrence of giant cell myocarditis in the transplanted heart which is successfully treated with high dose immunosuppression.
Case Media
ABClick to Enlarge
A. ECG, B. CXR
Episode Schematics & Teaching
CardioNerds Myocarditis, updated 1.20.21
Giant Cell Myocarditis Pearls
Giant cell myocarditis (GCM is a rare – and often fatal - cause of acute myocarditis. A hallmark of GCM is the presence of multinucleated giant cells; however, these may take 1-2 weeks to appear and can also be seen in sarcoidosis.Most etiologies of fulminant myocarditis do not have bradyarrhythmias as a prominent feature, and their presence should increase the suspicion for sarcoidosis, Chagas disease, or GCM.While non-specific, a clue to the diagnosis of GCM amongst other causes of myocarditis could be rapid clinical deterioration with minimal response to guideline directed therapy, including a lack of spontaneous recovery on mechanical support which more commonly occurs in fulminant lymphocytic myocarditis.Mechanical support is typically needed in the management of GCM, either as a bridge to transplantation or recovery.GCM can recur in the transplanted heart. This happens in up to 25% of transplant patients and warrants aggressive immunosuppression which usually is sufficient to ensure disease remission.
Notes - Giant Cell Myocarditis
What is Giant Cell myocarditis (GCM)?Giant cell myocarditis (GCM) is an extremely rare – and often fatal – cause of acute non-infectious myocarditis. The pathophysiology of GCM is poorly understood, but thought to be a T-cell mediated autoimmune process leading to diffuse or multifocal inflammatory infiltrate, including lymphocytes with multinucleated giant cells (note multinucleated giant cells are not exclusive to GCM and can be seen in sarcoidosis as well). It has been estimated to occur at a rate of 0.13 cases per 100,000 people (one in a million).It typically affects the myocardium in isolation and may not have any extracardiac manifestations, presenting with rapid hemodynamic deterioration, ventricular arrhythmias, and at times bradyarrhythmias. The rate of death or cardiac transplantation has been estimated at 89%, with a median survival of 5.5 months from the onset of symptoms to the time of death or transplantation.When should you be suspicious of GCM?The classic presentation is in a middle-aged Caucasian male who develops acute or subacute nonischemic cardiomyopathy (NICM) with clinical heart failure that progressively worsens. These patients often develop cardiogenic shock or arrhythmic instability – including both ventricular arrhythmia and conduction delays/heart block.
106. Case Report: A Hole in the HFpEF Diagnosis – Boston University, Massachusetts General Hospital, and Brigham and Women’s Hospital
Mar 08, 2021
CardioNerds (Amit Goyal & Karan Desai) join Dr. Alex Pipilas (FIT, Boston University) and Dr. Danny Pipilas (FIT, MGH) for in Boston, MA. Adult congenital heart disease expert Dr. Keri Shafer (Brigham and Women’s Hospital) provides the E-CPR expert segment. They discuss a case of heart failure secondary to sinus venosus defect with partial anomalous pulmonary venous return.
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Patient Summary
A 78-year-old woman with atrial fibrillation and heart failure with preserved ejection fraction presented with recurrent dyspnea and volume overload. A transthoracic echocardiogram demonstrated severe right ventricular enlargement and dysfunction. A CT pulmonary angiogram demonstrated partial anomalous pulmonary venous return and a transesophageal echocardiogram revealed a sinus venosus defect with left to right shunting. A right heart catheterization with oximetry saturation (“shunt run”) demonstrated pulmonary hypertension and a large left to right shunt (Qp/Qs ~ 3). She was referred for cardiac surgery and underwent repair of the sinus venosus defect and baffling of the anomalous pulmonary venous flow to the left atrium.
Case Media
ABCClick to Enlarge
A. CXR, B. ECG, C. TR Velocity
TTE: PLAX
TTE: RV Outflow
TTE: AP4
TEE: Sinus Venosus ASD
TEE: Sinus Venosus ASD 2
Episode Schematics & Teaching
Figure 1Figure 2
Pearls
It is critical to determine whether there is more to a diagnosis of heart failure with a preserved ejection fraction. Utilize all available clinical data and risk calculators to determine if there are more appropriate diagnoses causing the patients symptoms, especially when certain aspects of the presentation does not add up.Right ventricular failure may be related to pressure overload (i.e., pulmonary hypertension, PV stenosis), volume overload (i.e., tricuspid regurgitation, left to right shunt lesions), or primary myocardial process (i.e., ischemia, infiltration, ARVC). In cases of severe right ventricular enlargement and dysfunction without apparent cause, look for a left to right shunt lesion (i.e., VSD, ASD, PAPVR). Sometimes further imaging (TEE, cardiac CT, cardiac MRI) is necessary to detect these lesions if not visualized on TTE.Left to right shunts can be quantified in the cardiac catheterization laboratory by measuring oxygen saturation in each chamber and detecting an O2 “step up” (increase in oxygen saturation from one chamber to the next). Large left to right shunts are quantified using the Fick principle and comparing the ratio of pulmonary blood flow (Qp) to systemic blood flow (Qs).Large left-to-right shunts can cause right ventricular volume overload and pulmonary hypertension. Patients often present with signs and symptoms of right ventricular failure including shortness of breath, exercise intolerance, volume overload, atrial arrhythmias, and recurrent heart failure. Some may develop right-to-left shunting and possible paradoxical embolism.ACC/AHA guidelines recommend closure of a sinus venosus defect if the PA systolic pressure is < 50% systemic pressures AND PVR is <1/3 of SVR. It is a Class III recommendation (potentially harmful) to close a defect if PA systolic pressure is >2/3 of systemic systolic pressure and/or PVR >2/3 SVR.
Quotable:
About ACHD - “As we go through this physiology, I just want to remind all of the listeners out there that you have the opportunity to apply the knowledge you have from medical school about physiology to the adult human heart. You can’t make assumptions as we sometimes do in the setting of normal cardiac anatomy.
105. Narratives in Cardiology: Racial Disparities in Advanced Heart Failure with Dr. Bryan Smith and Dr. Shirlene Obuobi
Mar 03, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Bryan Smith (Advanced Heart Failure and Transplant Cardiologist at the University of Chicago) and Dr. Shirlene Obuobi (rising cardiology fellow, CardioNerds ambassador for the University of Chicago, and creator of ShirlyWhirl, M.D.) They discuss the story of a patient with end stage heart failure due to peripartum cardiomyopathy that highlights racial disparities in healthcare and advanced heart failure. They emphasize the importance of providing mentorship for Black and Indigenous People of Color (BIPOC) and share personal stories of their journey to Cardiology. Dr. Andi Shahu joins us to read his AHA blog titled "Let’s Ban the Phrase “Social Issues”: Social Justice and Advanced Heart Failure Therapies". Audio editing by CardioNerds Academy intern, Pace Wetstein.
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Quotables:
“One of the reasons why I went into Heart Failure is because I connected a lot with these young patients, a lot of these young black men and black women who were terrified of the hospital. As a resident and a fellow I would go talk to them and really understand their fears and where they are coming from. I think a lot of times these patients can be labeled as ‘noncompliant,’ or ‘withdrawn,’ or ‘aggressive,’ but a lot of times you just have to understand where they’re coming from. And I really found that just sitting down to talk to them, and to get to know them, I was able to help get them better, or a lot of them went on to get VADs or transplant. And, to be perfectly honest, I’m in touch with a lot of these patients who I met as a fellow who...I feel are part of my life....You have to meet patients where they are. Meaning you need to text them, interact with them on social media, and really connect with them in a way they understand.” Dr. Bryan Smith (12:10)
“Being black in America means not getting the benefit of doubt. ...I can’t help but wonder if unconscious bias among providers is imposing...unreasonable scrutiny on patients of color.” Shirlene (21:15)
“There are many different ways to combat [racial] disparities. As a Heart Failure physician we have these multidisciplinary meetings where we discuss patients for transplant. And I think it’s...important to highlight to our providers that how we discuss patients really matters. Language definitely matters. Heart failure is art in addition to science. ...Sometimes when discussing these patients...charged words are used, like ‘withdrawn,’ or ‘aggressive,’ or ‘ghetto’ even. And it’s all coded, racist language. ...Part of our responsibility is to educate everyone with implicit bias training....and to make sure we’re able to advocate for patients in the right way.” Dr. Bryan Smith (22:30)
“I’ve felt like I’ve been paying the minority tax...which is doing the necessary but unpaid and frequently seldom recognized labor of mentorship, community engagement, etc, and also of being hyper visible and acting as a symbol...” - Shirlene (24:52)
“It’s really easy when patients are in the hospital to think of them only as patients and forget that they’re people too, and that people are complex, they have complex emotions, they have reactions to things, sometimes those reactions aren’t necessarily what we would think are appropriate for their medical situation, but they’re what make us human.” - Shirlene (9:50)
Notes:
1. What are some of the racial disparities in diagnosis and outcomes of peri-partum cardiomyopathy, and what are some factors that might be contributing to those disparities?
CVD disease is the leading cause of pregnancy-associated mortality in the US. Black and American Indian/ Alaskan Native women are 3-4x more likely to die from a pr...
104. Nuclear and Multimodality Imaging: Anomalous Coronary Arteries & Myocardial Bridges
Mar 01, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of abnormal coronary anatomy including anomalous coronary arteries and myocardial bridges. Show notes were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
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Show Notes & Take Home Pearls
Five Take Home Pearls
Anomalous coronaries are present in 1-6% of the general population and predominantly involve origins of the right coronary artery (RCA). Anomalous origination of the left coronary artery from the right sinus, although less common, is consistently associated with sudden cardiac death, especially if there is an intramural course. Sudden cardiac death can occur due to several proposed mechanisms: (1) intramural segments pass between the aorta and pulmonary artery making them susceptible to compression as the great vessels dilate during strenuous exercise; (2) an acute angle takeoff of the anomalous coronary can create a “slit-like” ostium making it vulnerable to closure. Anomalous left circumflex arteries are virtually always benign because the path taken behind the great vessels to reach the lateral wall prevents vessel compression.Myocardial bridging (MB) is a congenital anomaly in which a segment of the coronary artery (most commonly, the mid-left anterior descending artery [LAD]) takes an intramuscular course and is “tunneled” under a “bridge” of overlying myocardium. In the vast majority of cases, these are benign. However, a MB >2 mm in depth, >20 mm in length, and a vessel that is totally encased under the myocardium are more likely to be of clinical significance, especially if there is myocardial oxygen supply-demand mismatch such as with tachycardia (reduced diastolic filling time), decreased transmural perfusion gradient (e.g. in myocardial hypertrophy and/or diastolic dysfunction), and endothelial dysfunction resulting in vasospasm.PET offers many benefits over SPECT in functional assessment of MB including the ability to acquire images at peak stress when using dobutamine stress-PET, enhanced spatial resolution, and quantification of absolute myocardial blood flow. For pharmacologic stress in evaluation of MB, we should preferentially use dobutamine over vasodilator stress. Its inotropic and chronotropic effects enhance systolic compression of the vessel, better targeting the pathological mechanisms in pearl 2 above that predispose a MB to being clinically significant.CCTA can help better define the anatomy of MB as well as anomalous origination of the coronary artery from the opposite sinus (ACAOS), help with risk stratification, and assist with surgical planning.Instantaneous wave-free ratio (iFR) measures intracoronary pressure of MB during the diastolic “wave-free” period – the period in the cardiac cycle when microvascular resistance is stable and minimized allowing the highest blood flow. This allows a more accurate assessment of a functionally significant dynamic stenosis than fractional flow reserve (FFR) – which can be falsely normal due to systolic overshooting.
Detailed Show Notes
What are some examples of abnormal coronary anatomies and how often do they lead to clinical events?Abnormal coronary anatomy can relate to the origin (e.g.
103. Case Report: A Rare Cause of Postpartum Angina and Arrest – University of Maryland
Feb 22, 2021
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Maryland cardiology fellows (Manu Mysore, Adam Zviman, and Scott Butler) for some cardiology and an Orioles game in Baltimore! They discuss a rare cause of postpartum angina and cardiac arrest due to coronary vasculitis. Program director Dr. Mukta Srivastava provides the E-CPR expert segment and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Rick Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
This case has been published in JACC Case Reports!
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Patient Summary
A woman in her early 30s with a past medical history of Hashimoto's thyroiditis and one prior miscarriage at <8 weeks presented with chest pain about 6 weeks postpartum from the birth of her third child. In the ED, she continued to report intermittent sharp chest discomfort and found to have a diastolic decrescendo murmur at the left upper sternal border and labs demonstrating a troponin-I of 0.07 ng/dL. Join the UMD Cardionerds for the incredible course and story of this young patient as we go through the differentia and approach to postpartum chest pain and ultimately arrive in a very rare diagnosis! For a detailed course, enjoy the JACC case report.
Case Media
Visit the JACC Case Reports to review the case media!
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. How Do We Evaluate Chest Pain in Younger Patients
Start with the same things as everyone else! Think broadly about the big three concerning etiologies of chest pain: Cardiac, Gastric, and Pulmonary (The excellent Clinical Problems Solvers 4+2+2 construct here is always a great resource. Find them at: https://clinicalproblemsolving.com/dx-schema-chest-pain/). Of course it is important to think about non-life threatening etiologies as well – esophageal spasm, gastric ulcer, rib fracture, skin lesion, among many others - given that high-risk chest pain is less likely in younger adults. While less common, acute coronary syndrome is not uncommon in young patients, as 23% of patients with MI present at age <55 years.
2. What About Chest Pain in Women?
As has been discussed on the Cardionerds podcast (Listen to episodes with Dr. Nanette Wenger, Dr Martha Gulati, and Dr. Leslie Cho), women generally present with acute coronary syndrome at a later age, with a higher burden of risk factors than men, and with greater symptom burden but are less likely to be treated with guideline-directed medical therapies, undergo cardiac catheterization and receive timely reperfusion. In one study of young patients with acute MI, women – 19% of cases overall – were less likely to undergo revascularization or receive guideline-directed therapy The construct of classifying chest pain as "typical" and "atypical" likely leads to misdiagnosis or delayed diagnosis of acute myocardial infarction in women. Rather, it is important to recognize that while symptoms may not be "typical" for angina, coronary disease can manifest in many different ways. While many women will presents with chest pain suggestive of angina, women are more likely than men to present with dyspnea, indigestion, weakness, nausea/vomiting and/or fatigue. Note, shoulder pain and arm pain are twice as predictive of an acute myocardial infarction diagnosis in women compared with men. Furthermore, while obstructive epicardial disease remains the primary cause of acute MI in young women,
102. Nuclear and Multimodality Imaging: Myocardial Viability
Feb 14, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of myocardial viability. Show notes & #Tweetorial were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
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Show Notes & Take Home Pearls
In response to ischemia the myocardium can dynamically change along a spectrum from myocardial stunning to myocardial hibernation to myocardial necrosis. The goals of viability testing are to identify patients who may benefit from revascularization as hibernating or stunned myocardium are potentially reversible causes of LV dysfunction. There are numerous imaging modalities available for the evaluation of myocardial viability. The broad range of ways in which myocardial viability is assessed speaks to the complexity of the disease spectrum and the difficulty in creating a unifying definition of viability to assess in clinical trials.
Five Take Home Pearls
1. In response to an acute episode of ischemia with subsequent reperfusion, the myocardium can be exposed to a large flux of oxygen free radicals or calcium overload that affects the cellular membrane and contractile apparatus. This phenotypically results in decreased contractility of the affected region of myocardium that can persist for weeks, labeled myocardial stunning
2. Repeated episodes of myocardial stunning or chronic low myocardial blood flow can lead to cellular changes such as resorption of the contractile apparatus in order to decrease oxygen demand and allow the myocardial cells to survive. Phenotypically, this might appear as regions of hypokinesis or akinesis at rest with a fixed perfusion defect on myocardial perfusion imaging. This is typically considered hibernating myocardium.
3. The goal of myocardial viability testing is to be able to differentiate between stunned, hibernating and necrosed myocardium. In patients with known epicardial coronary disease, this differentiation allows us to identify who may benefit from revascularization with improved LV systolic function and overall survival.
4. There are several imaging modalities that can be used in the assessment of myocardial viability. The most sensitive modalities are FDG-PET and CMR. The addition of Dobutamine or first pass perfusion with Gadolinium additionally increases the specificity of CMR. These modalities are more expensive and not as widely available.
5. The dynamic nature of the myocardial hibernation and the lack of a unifying definition/phenotypic expression of myocardial hibernation and viability have made it difficult for clinical trials to show that re-establishing myocardial blood flow to hibernating myocardium is beneficial. As Dr. Jaber stated in the episode in his spin on the classic opening phrase from Leo Tolstoy’s masterpiece, Anna Karenina, “All normal hearts are normal in the same way, and all abnormal hearts are abnormal in different ways.”
6. The PARR-2 trial was one of the few randomized, controlled trials of patients with LV systolic dysfunction and coronary artery disease who were randomized to either FDG-PET guided management or standard care with respect to whether to pursue revascularization. Overall,
101. Nuclear and Multimodality Imaging: Coronary Microvascular Disease
Feb 07, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of coronary microvascular disease. To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
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Guest Profiles
Wael Jaber, MD
Wael Jaber, MD, is a staff cardiologist in the Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, at the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. Dr. Jaber specializes in cardiac imaging (both nuclear cardiology and echocardiography) and valvular heart disease. Dr. Jaber attended college at the American University in Beirut, graduating with a Bachelor of Science in biology. He then went on at the American University to receive his medical degree while making the Dean's honor list. He completed his residency in internal medicine at the St. Luke's-Roosevelt Hospital Center at Columbia University College of Physicians and Surgeons, where he also completed fellowships in cardiovascular medicine and nuclear cardiology. Dr. Jaber is currently is the Medical Director of the Nuclear Lab and of the Cardiovascular Imaging Core Laboratory in C5Research. He is fluent in English, French and Arabic. He is the author of Nuclear Cardiology review: A Self-Assessment Tool and cofounder of Cardiac Imaging Agora.
Dr. Aldo L Schenone
Dr. Aldo L Schenone is one of the current Chief Non-Invasive Cardiovascular Imaging Fellows at the Brigham and Women's Hospital. He completed medical school at the University of Carabobo in Valencia, Venezuela, and then completed both his Internal Medicine residency and Cardiology fellowship at the Cleveland Clinic where he also served as a Chief Internal Medicine Resident.
Dr. Erica Hutt
Dr. Erika Hutt @erikahuttce is a cardiology fellow at the Cleveland Clinic. Erika was born and raised in Costa Rica, where she received her MD degree at Universidad de Costa Rica. She then decided to pursue further medical training in the United States, with the goal of becoming a cardiologist. She completed her residency training at Cleveland Clinic and went on to fellowship at the same institution. Her passions include infiltrative heart disease, atrial fibrillation, valvular heart disease and echocardiography among many. She is looking forward to a career in advanced cardiovascular imaging.
References and Links
Kaski, J.-C., Crea, F., Gersh, B. J., & Camici, P. G. (2018). Reappraisal of Ischemic Heart Disease. Circulation. https://doi.org/10.1161/circulationaha.118.031373Jaber, W., & Gimelli, A. (n.d.). Cardiac Imaging Agora. https://www.cardiacimagingagora.com/list/Taqueti, V. R., & Di Carli, M. F. (2018). Coronary Microvascular Disease Pathogenic Mechanisms and Therapeutic Options: JACC State-of-the-Art Review. In Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2018.09.042
Wael Jaber, MD
Dr. Aldo L SchenoneDr. Erika Hutt Dr. Madiha KhanAmit Goyal, MD
100. Women’s Heart Health & Women in Cardiology with Dr. Nanette Wenger – Special Go Red Encore
Feb 04, 2021
CardioNerds (Amit Goyal & Carine Hamo) discuss the past, present, and future of Women's Heart Health & Women in Cardiology with Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger is a true leader in the field of women’s heart health and a strong proponent for women in cardiology and medicine. Her passion, dedication, and advocacy have inspired countless trainees to carry this torch and continue to build on her truly impactful work. Special introduction by Dr. Martha Gulati. This is a special encore in recognition of the Go Red campaign and celebration of women's health.
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Episode graphic by Dr. Carine Hamo
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
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This episode initially ran as part of the CardioNerds Prevention Series which we produced in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention!
Cardionerds Cardiovascular Prevention Series
References and Links
1. Wenger NK (2005) Women in cardiology: The US experience. Heart.
2. Douglas PS, Rzeszut AK, Noel Bairey Merz C, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L (2018) Career preferences and perceptions of cardiology among us internal medicine trainees factors influencing cardiology career choice. JAMA Cardiol.
3. Wenger NK, Speroff L, Packard B (1993) Cardiovascular Health and Disease in Women. N Engl J Med.
4. Burgess S, Shaw E, Zaman S (2019) Women in Cardiology. Circulation.
Meet Dr. Wenger!
Dr. Nanette Wenger is Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger received her medical degree from Harvard Medical School in 1954 as one of their first female graduates followed by training at Mount Sinai Hospital where she was the first female to be chief resident in the cardiology department. She is among the first physicians to focus on heart disease in women with an expertise in cardiac rehabilitation and geriatric medicine.
Dr. Wenger has received numerous awards including the Distinguished Achievement Award from the Scientific Councils of the American Heart Association and its Women in Cardiology Mentoring Award, the James D. Bruce Memorial Award of the American College of Physicians for distinguished contributions in preventive medicine, the Gold Heart Award, the highest award of the American Heart Association, a Lifetime Achievement Award in 2009 and the Inaugural Bernadine Healy Leadership in Women’s CV Disease Distinguished Award, American College of Cardiology. She chaired the U.S. National Heart, Lung, and Blood Institute Conference on Cardiovascular Health and Disease in Women, is a Past President of the Society of Geriatric Cardiology and is past Chair, Board of Directors of the Society for Women’s Health Research. Dr. Wenger serves on the editorial boards of numerous professional journals and is a sought-after lecturer for issues related to heart disease in women, heart disease in the elderly, cardiac rehabilitation, coronary prevention, and contemporary cardiac care. She is listed in Best Doctors in America.
Carine Hamo, MDAmit Goyal, MD
99. Nuclear and Multimodality Imaging: Coronary Ischemia
Jan 31, 2021
CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of coronary ischemia. Show notes were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!
Collect free CME/MOC credit for enjoying this episode!
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Show Notes & Take Home Pearls
Five Take Home Pearls
1. We can broadly differentiate non-invasive testing into two different categories—functional and anatomical. Functional tests allow us to delineate the functional consequence of coronary disease rather than directly characterizing the burden of disease. Anatomical tests such as coronary CTA, on the other hand, allow us to directly visualize obstructive epicardial disease.
2. In general PET imaging provides higher quality images than SPECT imaging for a variety of reasons, including a higher “keV” of energy in PET radiotracers
3. If using a SPECT camera, we should use cameras that have attenuation correction. Without attenuation correction, the specificity of a SPECT camera drops to 50-60%.
4. In evaluating ischemic heart disease, cardiac nuclear imaging can provide a wide range of information including myocardial perfusion (rest and stress), ejection fraction assessment (rest and stress), absolute myocardial blood flow with quantitative flow reserve in all coronary territories (PET), assessment of myocardial viability (PET), and calcium score with CT attenuation correction.
5. To select the best non-invasive test, we should consider a variety of factors such as pretest probability of obstructive epicardial disease, patient-specific factors (e.g., ability to exercise) and whether a functional or an anatomical test will provide the best answer for our clinical question.
Detailed Show Notes
What are the basic non-invasive testing categories for evaluation of coronary artery disease? We have a variety of different non-invasive testing modalities that can be broadly separated into functional tests and anatomical tests. The basic principle underlying functional stress testing is to induce ischemia or coronary vasodilation (discussed below), followed by a functional assessment by different techniques (e.g., EKG, echocardiography, radionuclide imaging) to detect flow-limiting obstructive coronary artery disease. These tests delineate the functional consequence of the coronary disease, rather than directly characterizing the burden of disease itself. Functional tests can also allow us to assess the nature of a patient’s symptoms. For example, by having a patient exercise on a treadmill we can evaluate whether we can reproduce a patient’s chest pain syndrome. Anatomical tests allow us to visualize the presence of obstructive epicardial disease. For example, obtaining a Coronary Computed Tomography Angiography (CCTA) for a patient with chest pain would allow you to directly visualize possible obstructive epicardial disease.
How do we induce ischemia for functional stress testing? To induce ischemia (and/or coronary vasodilation), we have many different stressors that can be broadly separated into exercise stressors and pharmacologic stressors. Treadmill exercise via standardized protocols is the most common method for inducing ischemia and has the advantage of assessing functional capacity,
98. Personalized Risk Assessment for Cardiovascular Prevention with Dr. Amit Khera
Jan 25, 2021
CardioNerds (Carine Hamo, Amit Goyal and Daniel Ambinder) discuss personalized risk assessment for cardiovascular prevention with Dr. Amit Khera, the immediate past president for the American Society for Preventive Cardiology and Director of the Preventive Cardiology and Professor of Medicine at the University of Texas, Southwestern Medical School in Dallas, Texas. They dive into an illuminating discussion about traditional and next generation personalization of risk assessment which covers the need for personalization, traditional risk stratification, applying risk enhancing factors for decision making, biomarkers, familial hypercholesterolemia, and the use of -Omics. This episode is the 13th and final part of our in-depth prevention series produced in collaboration with the American Society for Preventive Cardiology!
Stay tuned for a bonus segment at the end of the episodeas we talk to Dr. Ankur Kalra, interventionist at the Cleveland Clinic, Podcast host of Parallax by Ankur Kalra, and founder of the non-profit startup, makeadent.org for a discussion about the CHAI (Cardiovascular Health in Asian Indians) Collaborative, an initiative that aims to identify genetic markers of heightened atherosclerosis in South Asians.
Episode graphic by Dr. Carine Hamo
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Show notes
Coming soon!
Cardionerds Cardiovascular Prevention Series
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Guest Profiles
Amit Khera, MD, MSc, FACC, FAHA, FASPC
Dr. Amit Khera is Professor of Medicine at the University of Texas, Southwestern Medical School in Dallas, Texas where he serves as Director of the Preventive Cardiology, and holder of the Dallas Heart Ball Chair in Hypertension and Heart Disease. He is also currently President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association. His clinical and research interests include the primary and secondary prevention of coronary artery disease, focusing on risk assessment and risk factor modification in those with premature and familial disease.
Dr. Khera received his undergraduate degree in American History from the University of Pennsylvania, with magna cum laude honors. He obtained his medical degree from Baylor College of Medicine where he served as class president and was inducted into the Alpha Omega Alpha honor medical society. He completed an Internal Medicine Residency at Brigham and Women’s Hospital, Harvard Medical School, followed by a Cardiology Fellowship at the University of Texas, Southwestern Medical Center. He also completed his Masters degree in Epidemiology at the Harvard School of Public Health.
He has published over 150 publications in the field of preventive cardiology and has served on numerous local and national committee and leadership roles for the American Heart Association, American College of Cardiology, and American Society for Preventive Cardiology.
97. Hypertension part 2 with Dr. Luke Laffin
Jan 18, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) are joined by Cleveland Clinic cardiology fellow Dr. Gregory Ogunnowo to discuss hypertension with Dr. Luke Laffin, cardiology faculty in the division of Preventive Cardiology and Rehabilitation and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Part 2 of this discussion covers the evaluation for secondary causes of HTN, approach to resistant HTN, interventional anti-hypertensive procedures, and a note on cardiac rehabilitation. Part 1 covered the definition of hypertension, correct measurement of blood pressure, nonpharmacologic HTN management, initial choice of BP agents, and hypertensive disorders of pregnancy.
Episode graphic by Dr. Carine Hamo
CardioNerds Cardiovascular Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
Show notes
Coming soon!
Cardionerds Cardiovascular Prevention Series
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Guest Profiles
Dr. Luke Laffin, serves as cardiology faculty in the division of Preventive Cardiology and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Dr. Laffin attended medical school at Vanderbilt University School of Medicine. He trained in internal medicine and cardiology at the University of Chicago where he completed a dedicated fellowship in hypertensive diseases. He is a clinical specialist in hypertension designated by the American Society of Hypertension – which has now merged with the AHA.
Dr. Gregory Ogunnowo is a cardiology fellow at the Cleveland Clinic. He completed medical school at the University of South Carolina School of Medicine in Columbia, South Carolina. He went on to complete internal medicine residency at Washington University School of Medicine in St. Louis where he stayed on as faculty in the Department of Hospital Medicine for a year prior to pursing fellowship. His interests include outcomes research in interventional cardiology and medical education In his spare time, Greg enjoys traveling, exercising, and experiencing new cultures through their food. When he’s not in the hospital, you can find Greg planning a trip with close friends and family.
References and Links
Coming soon!
Luke Laffin MDGreg Ogunnowo, MDAmit Goyal, MDDaniel Ambinder, MD
96. Hypertension part 1 with Dr. Luke Laffin
Jan 11, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) are joined by Cleveland Clinic cardiology fellow Dr. Gregory Ogunnowo to discuss hypertension with Dr. Luke Laffin, cardiology faculty in the division of Preventive Cardiology and Rehabilitation and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Part 1 of this discussion covers the definition of hypertension, correct measurement of blood pressure, nonpharmacologic HTN management, initial choice of BP agents, and hypertensive disorders of pregnancy. Be sure to follow-up with Part 2 to learn about evaluation for secondary causes of HTN, approach to resistant HTN, interventional anti-hypertensive procedures, and a note on cardiac rehabilitation.
Episode Graphic by Dr. Carine Hamo
CardioNerds Cardiovascular Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
Show notes
Coming soon!
Cardionerds Cardiovascular Prevention Series
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Guest Profiles
Dr. Luke Laffin, serves as cardiology faculty in the division of Preventive Cardiology and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Dr. Laffin attended medical school at Vanderbilt University School of Medicine. He trained in internal medicine and cardiology at the University of Chicago where he completed a dedicated fellowship in hypertensive diseases. He is a clinical specialist in hypertension designated by the American Society of Hypertension – which has now merged with the AHA.
Dr. Gregory Ogunnowo is a cardiology fellow at the Cleveland Clinic. He completed medical school at the University of South Carolina School of Medicine in Columbia, South Carolina. He went on to complete internal medicine residency at Washington University School of Medicine in St. Louis where he stayed on as faculty in the Department of Hospital Medicine for a year prior to pursing fellowship. His interests include outcomes research in interventional cardiology and medical education In his spare time, Greg enjoys traveling, exercising, and experiencing new cultures through their food. When he’s not in the hospital, you can find Greg planning a trip with close friends and family.
References and Links
Coming soon!
Luke Laffin MDGreg Ogunnowo, MDAmit Goyal, MDDaniel Ambinder, MD
95. Introducing Narratives in Cardiology Series: Dr. Pamela Douglas on Diversity & Inclusion
Jan 01, 2021
CardioNerds (Amit Goyal and Daniel Ambinder) introduce the CardioNerds Narratives in Cardiology Series which will feature the stories of amazing cardiovascular faculty and trainees representing diverse backgrounds, subspecialties, career stages, and career paths. To kick this series off, Dr. Pamela Douglas, who heads the Diversity and Inclusion task force for the American College of Cardiology, provides valuable insights in the field and shares her personal story. We are joined by the CardioNerds Narratives #FIT Advisors, Dr. Zarina Sharalaya, Dr. Norrisa Haynes and Dr. Pablo Sanchez for this very important discussion.
Special messages by: Dr. Vanessa Blumer, Dr. Robert Harrington, Dr. Richard Chazal, Dr. Nosheen Reza, Dr. Neha Pagidipati, Dr. Mary Norine (Minnow) Walsh, Dr. Melissa Daubert, Dr. Gerald Bloomfield, Dr. Angela Lowenstern, Dr. Ralph Brindis, Dr. Michael Valentine, Dr. Anna Lisa Crowley, Dr. Malissa Wood and Dr. Geoffrey Ginsberg.
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Show notes
What is "Diversity" & "Inclusion"?Facets of diversity are all aspects of human differences. These include gender, race, ethnicity, age, physical ability, gender identity, national origin, language, religion, sexual orientation, socioeconomic status, and more.Inclusion is making everyone feel welcomed and included.Inclusion requires having a culture & environment where everyone can thrive regardless of background differences. This inclusive culture fosters respect & belonging in which we hear, appreciate, & value everyone and their perspectives.Inclusive organizations work with individuals to recognize and eliminate both explicit and implicit biases. They may do this with intentional efforts like professional & skills development as well as addressing awareness, education, and policy. Diversity measures representation by counting the presence of varying identities and characteristics. But Diversity itself is not the final goal.Diversity is the metric while Inclusion is the goal. For now, while representation is so disparate among certain groups, diversity is an important metric. It’s hard to be truly inclusive with such professional inequities. “Ultimately what we want is for people to belong. So not just be asked to the dance and sitting around and staring at everybody else but really feeling like you can go out on that dance floor and dance, like nobody's watching and it's fine because this is your community.” - Pamela Douglas
Why is achieving diversity important?Diversity is a virtue in and of itself. But more than that, diverse groups make better decisions, are more innovative, are better at problem solving, and have an expanded talent pool.Cardiovascular medicine benefits from having a diverse workforce. Science performed by diverse groups has greater scientific novelty and produces higher impact papers in higher impact journals.
Is there a link between professional diversity and healthcare inequities?YES!Physician diversity reduces healthcare disparities and improves healthcare quality.Physicians who train in diverse environments are more culturally competent when treating underrepresented groups.Underrepresented physicians are more likely to serve underrepresented populations.Underrepresented patients are more likely to follow the recommendations of physicians who look like them. This enhanced trust is critical to an effective patient-physician relationship. In the context of clinical trials and guidelines, underrepresented physician scientists help diversify our clinical trial participants, resulting in a more robust and representative evidence base.
How are we doing in cardiology with respect to diversity?There have been improvements but we have a long way to go.Women comprise 43% of internal medicine resident physician...
94. Case Report: Altered Mental Status & Electrical Instability: DIGging through the Differential – University of Illinois at Chicago
Dec 28, 2020
CardioNerds (Amit Goyal & Karan Desai) join University of Illinois at Chicago cardiology fellows (Brody Slostad, Kavin Arasar, and Mary Rodriguez-Ziccardi) for a cup of tea from atop Hancock Tower! They discuss an illuminating case of altered mental status & electrical instability due to digitalis poisoning. Program director Dr. Alex Auseon and APD Dr. Mayank Kansal provide the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
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Patient Summary
A woman in her late 80s with history of systemic arterial hypertension and dementia presented with 2 weeks of nausea, vomiting, confusion, and yellow-tinted vision. When she presented to the hospital, initial history was limited as her caregiver was unaware of her medications and medical history. An initial ECG showed isorhythmic A-V dissociation and scooping ST segments laterally. Given her clinical history, this raised the suspicion for Digoxin toxicity, and a serum digoxin level was significantly elevated. However, this was not a home medication for the patient, nor did she have access to it! Listen to the episode now as the UIC Cardionerds masterfully take us through this case that would surely stump Dr. House!
Case Media
through the Differential
ABCDEFClick to Enlarge
A. Initial ECGB. CXR- Patchy opacities of the left lower lobe consistent with pulmonary edema and/or aspiration pneumonia.C. Repeat ECG: AF with AV block, persistent scooped T wavesD. Post arrest ECG: Flutter/fib with AV block, VERY LONG PAUSES up to 6 secondsE. ECG post TVP: A flutter, slow V response (pacing picking up), intrinsic ventricular rate 20-40, PM set to 50 bpmF. Most recent ECG: Normal sinus rhythm
TTE
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1) This episode featured a challenging case of digitalis toxicity. Cardionerds, what is the mechanism of action of cardiac glycosides?
Cardiac Glycosides (such as digoxin, digitalis, and oubain), inhibit the myocardial Na/K ATPase pump. This leads to an increased concentration of intracellular sodium, which then drives the influx of calcium into cardiac myocytes via the Na/Ca exchanger. This increase in intracellular calcium leads to further calcium release from the sarcoplasmic reticulum making even more calcium available to bind to troponin, increasing contractility. In addition to their effect on inotropy, cardiac glycosides increase vagal tone, reducing SA node activity and slowing conduction through the AV node by increasing the refractory period
2) The first published account of digitalis to treat heart failure dates back to the 18th century, when botanist and physician William Withering published "An account of the Foxglove and some of its medical uses with practical remarks on dropsy, and other diseases". A lot has changed over the years; what are some of the uses of digoxin in the modern day?
The DIG trial (1997) demonstrated a reduction in hospitalizations in patients with HFrEF treated with digoxin. However, no impact on mortality was shown. A major limitation from randomized trials of digoxin is the lack of contemporary background HF treatment (e.g., ARNI, SGLT2i, MRA, Device Therapy). Thus, its role in modern HFrEF management is typically limited to reducing hospitalizations in patients with persistent NYHA Class III or IV symptoms despite maximally tolerated guideline-directed medical therapy Digoxi...
93. Obesity for CardioNerds with Dr. Chiadi Ndumele
Dec 21, 2020
CardioNerds (Carine Hamo, Amit Goyal, and Daniel Ambinder) discuss the obesity epidemic and how it relates to the cardiovascular system with Dr. Chiadi Ndumele, cardiologist and epidemiologist at The Johns Hopkins Hospital and chairs the obesity subcommittee of the American Heart Association (AHA). They cover obesity definitions, epidemiology, strengths and limitations of different biometrics, including BMI, impact on myocardial structure and function, and current pharmacologic & surgical options for weight loss. They also discuss the practical approach to addressing obesity with patients. This episode was produced by Dr. Carine Hamo. Show notes & references by Dr. Daniel Ambinder.
Episode graphic by Dr. Carine Hamo
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Show notes
1. What is obesity and how do we define it at the personal and population level?
Obesity is when there is an excess and often dysfunctional adipose tissue that contributes to morbidity and to premature mortality The metric used to define obesity is Body Mass Index (BMI), defined as a person's weight in kilograms divided by the square of the person's height in meters (kg/m2) See WHO BMI classification below
2. What is the current epidemiology of obesity and are there certain populations that are affected more than others?
Rates of obesity are climbing. Currently, around 70% of the population meets criteria for being either overweight or obese and ~40% are at the level of obesity. Minorities such as African Americans, Native Americans, and Latinos have higher rates of obesity. Higher rates of obesity are also seen in groups with lower socioeconomic status. Certain populations, such as Southeast Asians, tend to develop severe metabolic consequences of obesity such as insulin resistance and cardiovascular consequences with less excess weight than other populations. Adult weight is very important but weight history (long standing obesity) plays a role as well when it comes to cardiovascular risk associated with obesity.
3. Currently the WHO classifies obesity based on BMI. What are the limitations to using BMI as a measure of obesity? Are their benefits to measuring waist circumference instead?
BMI is a far from a perfect measure but it correlates nicely at the population level with cardiovascular events and premature mortality BMI is more accessible than a direct quantitative or functional measure of adipose tissue A major limitation of BMI is that it does not reflect body composition. Body composition is very important in understanding risk associated with obesity. For example, football players may fall into the category of grade 1 obesity if just using BMI to classify their weight status. Waist circumference (WC) is a good way of getting a sense of body composition. Abdominal obesity is most closely linked to insulin resistance and various metabolic consequences such as diabetes, hypertension, and inflammation. This is why WC is incorporated into the metabolic syndrome construct. Adding WC measurements to the BMI measurements, particularly for individuals in the overweight and grade 1 obesity group (BMI 25-29.9, and 30-34.9) provides significant prognostic information about the development of cardiovascular disease.
4. How do obesity and metabolic syndrome impact myocardial structure and function? How does obesity and increased adiposity fit into the larger scheme of metabolic risk and metabolic syndrome?
Obesity is independently associated with myocardial remodeling and with increased heart failure risk. This contrasts with coronary heart disease (CAD) and stroke. For CAD and stroke, most associations with obesity are largely mediated by diabetes, hypertension and dyslipidemia. However, in heart failure, there is a strong unexplained association that remains after you consider those associated ...
92. Diabetes Mellitus for CardioNerds with Dr. Dennis Bruemmer
Dec 15, 2020
CardioNerds (Amit Goyal and Daniel Ambinder) discuss diabetes mellitus with Dr. Dennis Bruemmer. This is a must-listen for anyone engaged in the case of the cardiovascular patient. Given the alarming obesity epidemic, we anticipate a rising worldwide tide of diabetes mellitus and ensuing cardiovascular disease. Here we discuss the epidemiology and approach to diabetes management, with emphasis on what CardioNerds need to know. Dr. Bruemmer is board-certified in both cardiology and endocrinology, and is the director of the Center for Cardiometabolic Health in the section of Preventive Cardiology and Rehabilitation at the Cleveland Clinic.
Episode graphic by Dr. Carine Hamo
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Show notes
Why should CardioNerds pay attention to diabetes mellitus (DM)? As a cardiovascular risk equivalent, DM is a key CVD risk factor, associated with a 2-4 fold increased risk. 70% of ACS patients have DM. Cardiologists will see more patient with DM given the rising prevalence of obesity, subsequent diabetes and ensuing CVD. Only 6% of patients with DM and cardiovascular disease (CVD) get appropriate care for DM and CVD. Historically, hypoglycemic agents improved microvascular outcomes (retinopathy, nephropathy, neuropathy), but not macrovascular outcomes (MI, CVA, PAD). However, this has changed with the advent of mandatory cardiovascular safety trials with positive data for GLP1 agonists and SGLT2 inhibitors! There aren't enough endocrinologists! They only see ~5% of DM patients. In 2012 the US generated 280 endocrinologists versus 100 million patient with DM or pre-DM. Primary care physicians are key allies in the care of these patients. So as CardioNerds, let's get over this therapeutic inertia and take ownership of our patients' DM as we already do for their HTN and HLD; in collaboration with a multidisciplinary team including the PCP, dietician, pharmacist, DM educators, +/- behavioral therapist, +/- endocrinologist, +/- metabolic surgeon.
What is your global approach to the patient with DM? Optimize the non-DM CVD risk factors with lifestyle intervention and medical management: CVD risk factors are very common in patients with DM (sedentary lifestyle, unhealthy weight, HTN, HLD). The Steno-2 Study (Gaede et al., NEJM 2008) showed that in patients with T2DM & microalbuminuria, intensive intervention with multiple drug combinations and behavioral modification was better with regards to: vascular complications, death from any cause, and death from CV causes. Emphasize a healthy lifestyle - use a patient-centered approach with motivational interviewing and shared decision making, provide education, set realistic goals, identify barriers (socioeconomic, etc), engage family and a multidisciplinary team (nutritionist, exercise physiologist), utilize behavioral interventions. Pharmacologic intervention - medical weight loss for BMI > 27 and DM (enjoy upcoming Ndumele episode), anti-HTN (enjoy upcoming Laffin episode), and anti-HLD (enjoy the Navar-Shah episode). NOTE that statins have been shown to have a small effect on increasing incident or worsening DM, but the effect size is small and overcome by the benefit in whom statins are indicated. Treat the Hyperglycemia itself! Let's discuss this deeper…
What is your approach to non-insulin DM management? First-line agents: US guidelines: in addition to lifestyle intervention, start with metformin as the first line agent. European guidelines: now give preference to GLP1 agonists and SGLT2 inhibitors in patients with or at risk for cardiovascular disease. Sulfonylureas: increase pancreatic insulin secretion. Dr. Bruemmer feels they obsolete for the preventive cardiologist from the standpoints of safety, efficacy, and cardiovascular disease. There is no efficacy data past 4 years and no cardiovasc...
91. Aspirin, Vitamin D, Calcium & Omega 3 Fatty Acids Supplementation with Dr. Erin Michos
Dec 07, 2020
The CardioNerds (Carine Hamo and Daniel Ambinder) discuss aspirin as primary prevention, Vitamin D, Calcium, and omega 3 fatty acids supplementation with Dr. Erin Michos, director of women's cardiovascular health and the associate director of preventive cardiology with Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. We are also joined by Dr. Michos' mentees, Dr. Rick Ferraro, Dr. Andi Shahu, and student doctor Sunyoung (Sarah) Jang for a discussion about mentorship and career development. This episode was produced by Dr. Rick Ferraro and Dr. Carine Hamo. Show notes & references by Dr. Amit Goyal.
Episode graphic by Dr. Carine Hamo
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Show notes - Aspirin, Vitamin D, Calcium & Omega 3 Fatty Acids Supplementation
What is the role of aspirin for primary ASCVD prevention?
The Conundrum: ASCVD event rates are much lower in the primary prevention than in the secondary prevention population, BUT the bleeding rates are comparable. So in the primary prevention patients, the bleeding risk is just as high, but the propensity for benefit is lower. The Question: Does low dose aspirin have a place in the primary prevention of ASCVD events. The Data: ARRIVE Trial: in moderate risk nondiabetic patients without prior ASCVD events, there was no different in the composite ASCVD end point, but there was an increased risk of bleeding (mostly mild GI bleeding). Thus, in the moderate risk patients --> primary prevention aspirin has an unfavorable risk-benefit profile. The benefit in a higher risk (>10-20% estimated 10-yr risk) remains unclear. ASCEND Trial: In men and women age ≥ 40yrs with diabetes without prior ASCVD events, there was a modest benefit (NNT = 59 patients for 10 years to prevent 1 major ASCVD event) counterbalanced by a similar magnitude of harm (NNH = 77 patients for 10 years to cause 1 major bleeding event). Thus, in adults with diabetes --> primary prevention aspirin had a neutral risk-benefit profile. ASPREE Trial: in elderly patients (≥ 70 years; ≥ 65 years for Hispanic or Black patients) without prior ASCVD events, there was no difference in ASCVD events but there was a significant increase in bleeding events (NNH = 42 patients for 10 years to cause 1 major bleeding event). The trial was stopped early due to futility. Interestingly, there was higher all-cause mortality driven primarily by cancer. Importantly, patients had to have a life expectancy longer than 5 years and those with dementia, substantial physical disability, or high estimated bleeding risk were excluded. Thus, in elderly patients --> primary prevention aspirin led to overall harm. The Recommendations: There was insufficient evidence to recommend a specific risk threshold for starting primary prevention aspirin. This may be due to more widespread contemporary prevention strategies like lifestyle management, tobacco cessation, statin use, better blood pressure control, etc. Individualize the decision based on the totality of evidence for an individual's risk of ASCVD events versus bleeding events. Notably, those with higher ASCVD risk generally also have a higher bleeding risk. Class IIB: Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk. There may be a role for primary prevention aspirin in select adults with a high estimated ASCVD risk and low bleeding risk. CAC score ≥ 100 may help identify those might benefit from primary prevention aspirin. As always, shared decision making remains crucial. Class III: Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.
90. Case Report: Atrioesophageal Fistula (AEF) Formation after Pulmonary Vein Isolation – Thomas Jefferson University Hospital
Nov 18, 2020
CardioNerds (Amit Goyal) joins Thomas Jefferson cardiology fellows (Jay Kloo, Preya Simlote and Sean Dikdan - host of the Med Lit Review podcast) for some amazing craft beer from Independence Beer Garden in Philadelphia! They discuss a fascinating case of atrioesophageal fistula (AEF) formation after pulmonary vein isolation (PVI). Dr. Daniel Frisch provides the E-CPR and program director Dr. Gregary Marhefka provides a message for applicants. Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-60s with a history of paroxysmal Afib presented to the ED after one week of chest pain and altered mental status. His afib had been difficult to rate and rhythm control, and thus he had undergone catheter ablation with pulmonary vein isolation 3 weeks prior to presentation. In the ED he was found to be febrile and had a witnessed seizure. Blood cultures returned positive for Strep agalactiae and his CT head showed multiple areas of intravascular air. Join the Thomas Jefferson University Cardionerds as they take us through an expert discussion on the differential of post-catheter complications, the diagnosis of atrial-esophageal fistula and ultimately management of this potentially fatal complication!
Case Media
ABCDEFClick to Enlarge
A. ECG: Normal sinus rhythm HR 105 bpmB. CXRC. CT head: Multiple tiny foci of air throughout bilateral cerebral hemispheres. Appearance is most suggestive of intravascular air, although it is unclear if it is venous, arterial or both.D. MRI: 1. Restricted diffusion in bilateral cortical watershed zones, as well as in the posterior medial left cerebellar hemisphere, most consistent with recent infarctions.E. CT Chest: A small focus of air tracking along the left mainstem bronchus anterior to the esophagus, may represent a small amount of pneumomediastinum versus air in an outpouching of the esophagus. No air tracking more cranially along the mediastinal soft tissues. No definite soft tissue defect in the esophagus.F. Surgical repair of LA & Esophagus
Episode Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What is a pulmonary vein isolation? What are the most common complications? When is catheter ablation indicated?The majority of Afib triggers come from areas where the pulmonary veins attach to the left atrium. Approximately 15-20% of patients undergoing ablation will have non-pulmonary vein triggers. Guided by this anatomic and pathophysiologic underpinning, electrical isolation and ablation of these areas helps prevent propagati...
89. Case Report: Cardiac Arrest associated with Mitral Valve Prolapse with Mitral Annular Disjunction – Oregon Health & Science University
Nov 17, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Oregon Health & Science University cardiology fellows (Miranda Merrill, Timothy Simpson, Kris Kumar, and Stacey Howell) for a riverside chat at the Portland waterfront! They discuss a case of cardiac arrest associated with mitral valve prolapse (MVP) with mitral annular disjunction (MAD). Dr. Punag Divanji provides the E-CPR and program director Dr. Hind Rahmouni provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
Coming soon!
Case Media
ABCDEFGClick to Enlarge
A. CXRB. Rhythm Strips - ventricular fibrillationC. ECG: 1st degree AVB (PR ~ 215), borderline RAD, Qtc ~460 msec, slight ant. convexity with inferior terminal T waveD: TTE E: TTE with Pickelhaube Spike seen in mitral valve prolapse F-G: Cardiac MRI
TTE 1
TTE 2
TTE 3
Cardiac MRI
Episode Schematics & Teaching
Coming soon!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Coming soon!
References
Coming soon!
CardioNerds Case Reports: Recruitment Edition Series Production Team
Bibin Varghese, MDRick Ferraro, MDTommy Das, MDEunice Dugan, MDEvelyn Song, MDColin Blumenthal, MDKaran Desai, MDAmit Goyal, MDDaniel Ambinder, MD
88. Case Report: Severe Mitral Stenosis Treated with Valve-in-MAC TMVR with LAMPOON – Emory University
Nov 15, 2020
CardioNerd (Amit Goyal) join Emory University School of Medicine cardiology fellows (Sonali Kumar, John Lisko, and John Ricketts) for a lovely stroll on the BeltLine in Atalanta, GA. They discuss an interesting case of severe mitral stenosis treated with Valve-in-MAC transcatheter mitral valve replacement (TMVR) with LAMPOON. Drs. Vasilis Babaliaros and Adam Greenbaum provide the E-CPR and program director Dr. B. Robinson Williams III provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
Coming soon!
Case Media
ABCDEFGHI JKClick to Enlarge
A. CXRB. ECGC. TTE: Trasns-mitral PW Doppler D. Laceration in swineE-F: CT planningG. Transeptal catheters H. Trans-mitral PW Doppler (post procedure) I. LVOT gradients J-K. Post procedure CT
TTE 1
TTE 2
TTE 3
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TEE 2
Fluoroscopy 1
Fluoroscopy 2
Fluoroscopy 3
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https://youtu.be/1gUyat6pg30
LAMPOON Procedure
Episode Schematics & Teaching
Coming soon!
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Coming soon!
References
Coming soon!
CardioNerds Case Reports: Recruitment Edition Series Production Team
Bibin Varghese, MDRick Ferraro, MDTommy Das, MDEunice Dugan, MDEvelyn Song, MDColin Blumenthal, MDKaran Desai, MDAmit Goyal, MDDaniel Ambinder, MD
87. Case Report: Giant Coronary Aneurysm Presenting with Heart Failure – University of Hawaii
Nov 13, 2020
Aloha! CardioNerds (Amit Goyal & Karan Desai) join University of Hawaii cardiology fellows (Isaac Mizrahi, Nath Limpruttidham, Nishant Trivedi, and Shana Greif) for some shaved iced on the Big Island's north shore! They discuss a fascinating case of a patient presenting with decompensated heart failure found to have a giant coronary aneurysm. Program director Dr. Dipanjan Banerjee provides the E-CPR as well as a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his early 60s with history of hypertension, peripheral arterial disease, atrial fibrillation, and AAA s/p repair presented with subacute fatigue, palpitations, shortness of breath, and lower extremity edema. On exam he was warm and well perfused, though hypotensive, tachycardic with an irregular rhythm, and had an elevated JVP. ECG showed AF with RVR without evidence of acute MI, and troponin was negative. TTE revealed a reduced LVEF and WMA in the inferolateral walls with akinesis of the basal mid septum; additionally, two large extracardiac structures were noted, one with heterogenous echotexture in the AV groove, and a second with an echolucent interior adjacent to the RA.
The patient underwent coronary angiography, showing a dilated and calcified proximal LAD with high grade stenosis adjacent to the first septal perforator, a ectatic LCX that supplied left to right collaterals, and a giant RCA aneurysm with TIMI 0 flow distally. CCTA confirmed these findings, showing thrombosed aneurysms of the LAD, LCX, and RCA. Interventional cardiology and cardiac surgery both evaluated the patient's case, and determined that he was not a candidate for intervention. He was ultimately diuresed to euvolemia with significant improvement in symptoms, and plans to follow-up as an outpatient for heart transplant evaluation.
Case Media
ABCDClick to Enlarge
A. CXRB. ECG: atrial fibrillation with RVR, left axis deviation, poor r wave progressionC. Wide complex tachycardia D. CT chest demonstrating giant aneurysm
TTE
Coronary Angiography
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1) This case featured a patient with a giant coronary aneurysm – how are coronary artery aneurysms defined and classified?
Coronary artery aneurysms (CAA) are defined as a focal dilation of a coronary segment at least 1.5x the adjacent normal segment. Contrast this with coronary artery ectasia, which refers to a diffuse, as opposed to focal, coronary dilation. CAA morphology can be classified as either saccular (transverse > longitudinal diameter) or fusiform (transverse < longitudinal diameter). Giant CAA's are >20mm in diameter. Aortocoronary saphenous vein graft aneurysms have distinct characteristics and natural history compared to native coronary aneurysms. These aneurysms tend to present late (e.g., > 10 years following CABG) and tend to be larger than native CAA. IVUS can help differentiate between a true aneurysm with preserved integrity of all 3 vessel layers (intima, media, and adventitia) and a pseudoaneurysm with loss of wall integrity and damage to the adventitia.
2) Now that we have the language to define and classify coronary artery aneurysms, what are some causes these lesions?
Atherosclerosis: lipid deposition, focal calcification, and fibrosis can weaken the vessel wall and predispose to subsequent coronary artery dilation. Up to 50% of CAAs are linked to arteriosclerosis.
86. Case Report: Histoplasmosis Pericarditis Complicated by Cardiac Tamponade – Georgetown University
Nov 12, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Georgetown University/Washington Hospital Center cardiology fellows (Nitin Malik, AJ Grant, and Tsion Aberra) for some fresh Maryland blue crab cakes at the Georgetown waterfront in Washington, DC. They discuss a rare case of histoplasmosis pericarditis complicated by cardiac tamponade. Dr. Patrick Bering provides the E-CPR and program director Dr. Gaby Weissman provides a message for applicants. Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her early 30s with a history of Crohn's disease on TNF-inhibitor therapy and chronic prednisone presented to the ED after two months of abdominal pain and fevers. She was found to have a perforated bowel and taken to emergent surgery and eventually found to have disseminated histoplasmosis. Post-surgery, her hypotension worsened. At this point, the Georgetown University Cardionerds were involved. Listen to the podcast now to learn about histoplasmosis, it's cardiac involvement, and management of acute effusive pericarditis!
Case Media
ABCDEClick to Enlarge
A. Left: Admission chest x-ray (PA film), which was overall unremarkable. Right: Chest x-ray from hospital day 12 - which revealed pulmonary edema with bilateral perihilar haziness, increased prominence of pulmonary vascularity, and small-moderate bilateral pleural effusions. Note increased size of cardiac silhouette. At the corresponding time, pericardial effusion (without tamponade) had been diagnosed.B. EKG: Sinus tachycardia and low-voltage QRS complexes.C. CT abdomen/pelvis on hospital day 14. Free air noted within the abdomen (left). Moderate pericardial effusion also incidentally appreciated (right).D. Pulse-Wave Doppler of mitral inflow. Flow variation is present, but variation is less than <30%.E. (A) Small bowel resection showing focal mucosal ulceration, serositis, and formation of a granuloma. (B) Transmural inflammation seen on small bowel resection. (C) Pathology of ileocecectomy showing focal histoplasmosis characterized by intracytoplasmic yeast-like forms (black circles)
Parasternal short axis view on echocardiogram showing a moderate pericardial effusion without diastolic septal flattening.
Apical view showing profound tachycardia but without chamber collapse. Ejection fraction was moderately reduced.
Parasternal short axis view on echocardiogram showing a moderate pericardial effusion with intermittent septal flattening.
Apical view showing early diastolic RV chamber collapse.
Episode Schematics & Teaching
85: Case Report: Exertional Intolerance due to Tricuspid Regurgitation – Medical University of South Carolina
Nov 11, 2020
CardioNerds (Amit Goyal & Karan Desai) join Medical University of South Carolina cardiology (MUSC) fellows (Carson Keck, Samuel Powell, and Ishan Shah) at MUSC Children's Hospital cafeteria overlooking the gorgeous Charleston Harbor. They reflect on an informative case of exertional intolerance due to tricuspid regurgitation. Dr. Ryan Tedford provides the E-CPR and program director Dr. Daniel Judge provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
Coming soon!
Case Media
ABClick to Enlarge
A. Tricuspid valve CW DopplerB. Hepatic vein flow
TTE: TV inflow
TTE: TV inflow with color Doppler
TTE: Apical 4 chamber
TTE: RV focused color
Cardiac MRI - 4 chamber CINE
Cardiac MRI - Short-axis stack CINE
Episode Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Coming soon!
References
Coming soon!
CardioNerds Case Reports: Recruitment Edition Series Production Team
Bibin Varghese, MDRick Ferraro, MDTommy Das, MDEunice Dugan, MDEvelyn Song, MDColin Blumenthal, MDKaran Desai, MDAmit Goyal, MDDaniel Ambinder, MD
84. Case Report: Hypertrophic Cardiomyopathy with Superimposed Stress Cardiomyopathy – Brown University
Nov 11, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Brown University cardiology fellows (Greg Salber, Vrinda Trivedi, and Esseim Sharma) for a gorgeous coastal boat ride in Providence, RI. They discuss an educational case of hypertrophic cardiomyopathy with superimposed stress cardiomyopathy. Dr. Katharine French provides the E-CPR and program director Dr. Raymond Russell provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-70s with history of hypertension and diabetes presented with chest pain and ST elevation in V1-V3. Two weeks prior to his presentation he was diagnosed with HoCM after several months of progressive dyspnea. TTE at that time showed HCM with resting left ventricular outflow gradient of 35 mmHg and 83 mmHg with valsava and systolic anterior motion (SAM) of the mitral valve. Join the Brown University Cardionerds as they take us through the differential of chest pain in HCM, approach to wall motion abnormalities, and the fascinating management questions that arise.
Case Media
ABCDEClick to Enlarge
A. ECG 2 weeks prior to current presentation B. Current ECG C. CXRD. M mode though the mitral valve demonstrating systolic anterior motion of the mitral valveE. LVOT CW Doppler tracings with a peak velocity ~ 5 m/s
Coronary angiography - 1
Coronary angiography - 2
TTE - 1
TTE - 2
TTE - 3
TTE - 4
Cardiac MRI
Episode Schematics & Teaching
Hypertrophic Cardiomyopathy InfographicClick to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What's the differential for LVH and what findings are more suggestive of HCM?
Causes for LVH can be either pathological or physiological. Pathological causes include infiltrative diseases like hypertrophic cardiomyopathy (HCM), Amyloidosis, or Fabry disease and inflammatory diseases like myocarditis.Physiological causes are due to remodeling from increased cardiac output or workload like in athletic heart or from a high afterload state such as in aortic stenosis and hypertension.In hypertension, AS, and athletic heart, LV hypertrophy is more commonly concentric and rarely exceeds 15mm. In HCM, LV hypertrophy is more commonly asymmetric (basal anteroseptum > posterior wall), often >15mm, and typically involves the basal ventricular septum.Differentiating pathologic versus physiologic causes of LVH can typically be done from a detailed history and exam (e.g., evidence of hypertrophy out of proportion to pressure overload,
83. Living with Adult Congenital Heart Disease: The Life & Legacy of Jeremy Keck
Nov 10, 2020
In Episode #82, we met Jeremy Keck as a patient born with L-TGA and DILV treated with Fontan procedure. Now, in this very special episode, we meet Jeremy Keck beyond his heart disease through the eyes of his loving wife Ana Keck. His legacy underscores the importance of seeing our patients as people beyond their illness, in the context of their lives, values, and loved ones. We learn to appreciate the full life one can live with complex adult congenital heart disease but also of the work that remains to be done. This powerful discussion is led by Dr. Evelyn Song (internal medicine resident at Johns Hopkins Hospital), Dr. Pablo Sanchez (cardiology fellow at Stanford University), and Dr. Michael Landzberg (cardiovascular and palliative care faculty and former director of ACHD at Brigham and Women’s Hospital).
Jeremy's gofundme pageJeremy's case discussion - episode 82Jeremy's obituary page
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In Loving Memory of Jeremy Keck
Jeremy Keck was a giant within the construction industry and accomplished so much in his 37 years of life. However, his greatest point of pride was his family. He is survived by his wife Ana, two young daughters, Emilee and Kaylee, his parents, Jeff and Terri Keck, brother Kevinn (Deana) Keck, nephews Jeremy and Payne, and nieces Taylore and Payge. Jeremy also had a heart for philanthropy. He was an active supporter of the Heart Center at Phoenix Children's Hospital.
In an interview with The Arizona Republic in 2015, Jeremy said he wouldn’t change his experience even if he had the chance. “I have a perspective on life that you can't teach anybody," he said. “You can't even explain it to people. The small things that happen that might not go your way seem pretty minor.” Jeremy had such a positive impact on those around him, inspiring everyone to live life to the fullest. He will be deeply missed.
Visit Jeremy's gofundme page for more information.
Music AcknowledgementsEternal Hope by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1100238. Artist: http://incompetech.com/
82. Case Report: L-TGA with Double Inlet LV post-Fontan complicated by VF Arrest – Stanford University
Nov 06, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Stanford cardiology fellows (Pablo Sanchez, Natalie Tapaskar, Jimmy Tooley) for tacos while enjoying the sunshine on the Stanford Oval! They recount the story of a man with adult congenital heart disease (ACHD): L-TGA (levo-transposed great arteries) with double inlet LV post-Fontan complicated by VF arrest. Dr. Christiane Haeffele provides the E-CPR and program director Dr. Joshua Knowles provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai and Cleveland clinic cardiology fellow Josh Saef.
Jump to: Patient summary - Case media - Case teaching - References
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-30s with past medical history notable for L-TGA (levo-transposed great arteries) with double inlet LV s/p Fontan palliation was playing golf when he suddenly collapsed. EMS arrived after three minutes of bystander CPR. An AED indicated the patient had suffered a VF arrest. ROSC was achieved after 1 round of Epi and 1 shock delivered. He was intubated and started on targeted temperature management protocol. Home medications were notable for digoxin 0.25mg daily, sotalol 120mg BID, and warfarin 5mg daily. Initial labs were notable for Na 127, K 5.4, Cr 1.0 (unknown baseline), INR 4.5, Lactate 4.6, Troponin-I 0.532, VBG 7.06/61, and random Digoxin level 2.7. EKG showed AV sequential pacing at a rate of 70 bpm. QTc prolonged at 571ms. No ischemic ST changes. Device interrogation showed sustained VT for 5 minutes prior to external shock. No internal shock was delivered. He was initially stabilized and his acidosis and hyperkalemia were corrected. Course was complicated by hemoptysis due to alveolar hemorrhagic and he was given concentrated prothrombin complex to reverse his coagulopathy. He eventually stabilized, and a formal TTE was obtained which showed a hypoplastic RV, single dilated LV with an akinetic posterior wall and hypokinetic lateral wall, all similar to his prior TTE in 2019. No obstruction noted at the IVC/Fontan anastomotic site. Coronary angiogram performed after his kidney function improved also did not show any significant obstructions or coronary anomalies. After multidisciplinary discussion, his VF arrest was attributed to a combination of prior ventricular fibrosis/scar, suspected digoxin toxicity, sotalol, dehydration, and renal failure. He had a subcutaneous ICD lead placed and was ultimately discharged home.
Case Media
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A. CXRB. ECG
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What's Transposition of the Great Arteries (TGA)?
81. Case Report: Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) – Massachusetts General Hospital
Nov 05, 2020
CardioNerds (Amit Goyal & Karan Desai) join Massachusetts General Hospital cardiology fellows (Daniel Pipilas, Rachel Frank and Kemar Brown) on a luxurious sailboat for iced coffees and Modern Pastry delicacies! They discuss a rare case of Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA). Program director, Dr. Doreen DeFaria Yeh provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A women in her early 30s who's a Jehovah's witness presented with three days of intermittent chest pain. Past medical history included anxiety. Initial vitals and physical exam were unremarkable. Labs were notable for an elevated troponin T of 360 ng/L and a low TSH of 0.02 mIU/L with an elevated free T4 of 5.1 ng/dL. EKG demonstrated lateral and inferior ST depressions. TTE demonstrated a normal LVEF of 58% with a subtle anterolateral wall motion abnormality. Given her lack of conventional risk factors for CAD, resolution of her chest pain, and downtrending troponin, coronary CTA was obtained next which did not show any CAD but demonstrated an anomalous left main coronary artery (LMCA) arising from the main pulmonary artery with evidence of left to right shunting from the left main into the PA and extensive coronary and bronchial collateralization. The anterior wall hypokinesis was also seen on CT, consistent with ischemia due to myocardial steal phenomenon. Given the abnormal thyroid function tests, thyroid US was also obtained which showed patchy heterogeneity consistent with thyroiditis. Ultimately, the patient was diagnosed with ALCAPA and her chest pain was attributed to steal phenomenon due to hyperthyroidism and increased cardiac demand. She was treated with long-acting nitrates and beta-blocker with resolution of symptoms and was referred to cardiac surgery on discharge.
After a multidisciplinary discussion involving the cardiac surgery team, patient underwent ligation of LMCA with SVG bypass to LAD. One month after operation, she developed palpitations and chest pain during exertion and was taken to the hospital. Labs showed an elevated hs-troponin T of 711 ng/L and she was treated for type 1 NSTEMI with aspirin, heparin drip, and statin. Repeat TTE demonstrated normal LVEF and lack of WMA. LHC showed occlusion of SVG graft and possible thrombus in LAD near the site of graft anastomosis. RCA was large and patent, providing adequate collaterals to the left coronary system. Ultimately, PCI was deferred and medical management was pursued because she had adequate collaterals from right coronary system. She was treated with DAPT, beta-blocker, and atorvastatin and has been doing well since.
Case Media
ABCDEFClick to Enlarge
A. CXRB. ECG C. Follow up ECGD-F. Cardiac CT
TTE 1
TTE 2
Angiography 1
Angiography 2
Angiography 3
Angiography 4
Angiography 5
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
How are the coronary arteries formed during embryology and how are anomalous coronary arteries formed? During embryology, according to one theory, the coronary ostia and artery formation begins with ingrowth of a capillary plexus into the aortic sinuses. This complex process heavily depends on the proliferation and migration of cells that originate outside the heart at the sinus venosus and then differentiate into endothelial cells, vascular smooth muscle cells, and fibroblasts.
80. Case Report: Prosthetic Valve Endocarditis with Aortic Regurgitation – Brigham and Women’s Hospital
Nov 04, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Brigham and Women’s Hospital cardiology fellows (Mounica Yanamandala, Simin Lee and Maria Pabon Porras) for some fun times at the Charles River Esplanade! They discuss a complicated case of prosthetic valve endocarditis with aortic regurgitation. Dr. Dale Adler provides the E-CPR and program director Dr. Donna Polk provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A male in his mid-40s with history of HIV on ART (undetectable VL, CD4 320) and idiopathic thoracic ascending aortic aneurysm (TAAA) with AR s/p bioprosthetic valve replacement 10 years prior presented with acute onset lightheadedness and pre-syncope. He was diagnosed with an idiopathic TAAA at age 30 after he was noted to have an incidental murmur. Over the next few years, his aortic root increased to over 7 cm with severe AR, LV dilation, and reduced LVEF of 45%. He underwent bioprosthetic aortic valve replacement and root repair with a Medtronic freestyle porcine aortic root with subsequent recovery of his LVEF to 50% and improved LV dilation. Thereafter, he was doing well until he reported a flu like illness 3 weeks prior to presentation with reported fever up to 101.3 F and associated myalgias. He denied any sick contacts or recent travel and was adherent to his HIV regiment. On the day of presentation, he was walking his dogs when he developed acute onset lightheadedness with presyncope. On presentation, he had a low grade fever, tachycardia, tachypnea, and hypoxia. On exam, cardiac exam was notable for loud blowing diastolic murmur, non-distended JVP, decreased breath sounds, warm extremities with bounding pulses and without edema. There were no stigmata of endocarditis. Labs revealed elevated cardiac and inflammatory biomarkers. Blood cultures were initially NGTD. CXR corroborated the exam with bilateral interstitial and airspace opacification with effusions. TTE showed LVEF 35% with global hypokinesis, dilated LV with LVEDD 7.5 cm, mild RV systolic dysfunction, severe AR with holo-diastolic flow reversal in the abdominal aorta, no prosthetic stenosis, and aortic root 31 mm. TEE showed a well-seated AVR with leaflet thickening and several echodensities. CT surgery deemed patient to be high risk for the OR. After a few days, patient required intubation for increased work of breathing and acute decompensation requiring vasoactive infusions. After multidisciplinary discussions, the patient ultimately underwent ViV TAVR with successful placement of a 29 mm E...
79. Case Report: Recurrent Troponin Elevation – University of Washington
Nov 03, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Washington cardiology fellows (Shannon McConnaughey, Betty Ashinne and Andrew Perry - host of the AP Cardiology podcast) for some tacos and beer at the water and discuss a puzzling case of recurrent troponin elevation. Dr. Kelly Branch provides the E-CPR and program director, Dr. Rosario Freeman, provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Eunice Dugan with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A female is her late 50s with past medical history of alcohol use disorder and intravenous drug use complicated by hepatitis C presented with generalized weakness and was found to have lower extremity fractures. Cardiology was consulted for pre-operative management. When obtaining a cardiac history, she reported rare, intermittent, and non-anginal chest pain. She had no current chest pain or dyspnea. On chart review, she had multiple presentations over the past 3 years for various complaints - some were chest pain - during which she was found to have elevated troponin I values. Most of the elevations were in the 0.5 to 1 ng/mL range, but one time, her peak troponin was 32 ng/mL. At one of those presentations, she had a TTE that showed septal wall motion abnormalities. She underwent coronary angiography on two occasions, which both showed proximal and mid-LAD calcifications, but no significant stenosis and she was managed medically.
At the current presentation, her vitals were within normal limits and her exam did not show any cardiopulmonary abnormalities. Labs were notable for troponin I of 10 ng/mL but CK-MB was normal. Interestingly, alkaline phosphatase was 3 times the upper limit of normal, and rheumatoid factor was 1156 IU/mL compared to 70 previously (normal range 0-20 IU/mL). EKG was without ischemic changes. TTE showed no wall motion abnormalities, normal LVEF, and no significant valvular disease. Cardiac catherization was deferred, and the patient was not interested in cardiac MRI. Due to an incongruent troponin elevation with the clinical presentation, there was concern for interference with the troponin assay due to the elevated rheumatoid factor and alkaline phosphatase levels. Upon further investigation, dilution of the troponin yielded results lower than factor of dilution or undetectable results. Mayo testing of the sample showed troponin-T of 0.024 ng/mL (normal < 0.01 ng/mL), and troponin I of 0.02 ng/mL (normal < 0.04 ng/mL). Although there were still some aspects of her previous presentations including rising troponin pattern and previous wall motion abnormalities that are unexplained at this time, her troponin elevation at this presentation was attributed to assay interference.
Case Media
ABCClick to Enlarge
A. ECG from MayB. Coronary angiography form MayC. ECG August (same year)
TTE 1 (May)
TTE 2 (May)
TEE 3 (May)
TTE 4 (May)
TTE 1 (August)
TTE 2 (August)
TTE 3 (August)
TTE 4 (August)
Episode Schematics & Teaching
Coming soon!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What is the universal definition of myocardial infarction?
· As per the current 4th universal definition, myocardial infarction is defined as an elevation in cardiac troponin (cTn) above the 99th percentile in high sensitivity assays in the setting of acute myocardial ischemia. It is considered acute if there is a characteristic rise/fall pattern in cTn.
78. Case Report: Severe Functional Mitral Regurgitation treated with MitraClip – University of Mississippi Medical Center
Nov 01, 2020
CardioNerds (Amit Goyal) join University of Mississippi Medical Center cardiology fellows (Catherine Lowe, Chris Latour and Adi Sabharwal) as they sit at the reservoir enjoying a great view of the water at the Pelican Cove Grill in Jackson, MS. They discuss and educational case of decompensated heart failure and shock in the setting of severe functional mitral regurgitation treated with MitraClip. Dr. Kellan Ashley provides the E-CPR and program director Dr. Trey Clark provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man his mid 70s with a history of non-ischemic heart failure status post CRT-D placement, A-Fib, and chronic kidney disease presented with progressive shortness of breath with limited exertion. The patient was found to have severe secondary mitral regurgitation. Listen to the episode now to learn about treatment options for severe mitral regurgitation in heart failure and specifically the evaluation for MitraClip!
Case Media
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A. Right atrial pressure B. Right ventricular pressureC. Pulmonary artery pressureD. Wedge pressureC. Pre and post MitraClip left atrial pressure
Episode Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. What is Comprehensive Disease Modifying Therapy in HFrEF?
Comprehensive disease modifying therapy for heart failure with reduced ejection fraction (HFrEF) has become both more robust and better understood by practitioners inside and outside the cardiology community. Comprehensive therapy is generally considered to consist of beta-blockade, mineralocorticoid receptor antagonist (MRA), sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor neprilysin inhibitor (ARNI), with ARNI being the preferred agent over angiotensin converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB). Despite a greater understanding of HFrEF therapy by the medical community, significant gaps remain with recent data showing few patients on concomitant beta blockade, MRA, SGLT2i and ACE/ARB/ARNI, and even fewer at target doses. Compared to ACE, BB, and MRA alone, comprehensive therapy with MRA, BB, SGLT2i and ARNI could add an additional 6 years for middle-aged patients.
2. What role does Mitral Valve Disease have in Heart Failure Exacerbations?
For patients that remain symptomatic or with repeated hospitalizations for decompensated heart failure despite comprehensive therapy, it is important to look for additional pathology contributing to h...
77. Case Report: Carcinoid Heart Disease with Severe Tricuspid Regurgitation – Boston University Medical Center
Oct 28, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Boston University cardiology fellows (Yuliya Mints, Anshul Srivastava, and Michel Ibrahim) for some hotdogs at Fenway Park in Boston, MA. They discuss an educational case of carcinoid heart disease with severe tricuspid regurgitation. Program director, Dr. Omar Siddiqi provides the E-CPR and APD Dr. Katy Bockstall provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her mid 60s with history of neuroendocrine tumor (NET) presented to the cardio-oncology clinic with chronic progressive SOB and fatigue. She was diagnosed with NET after presenting with a small bowel obstruction (SBO) several years prior. At the time, she was found to have liver and pulmonary metastasis with MR enterography showing thickening of the terminal ileum. Ileocecetomy and biopsy of the liver lesions confirmed metastatic NET. Despite treatment with octreotide and everolimus, follow up CT showed progression of liver lesions and she was eventually started on telotristat and enrolled in a clinical trial. On presentation, she was not tachycardiac, hypotensive or requiring oxygen supplementation (KD: Correct?). On exam, she demonstrated elevated JVP with a positive hepato-jugular reflex and a 3/6 holosytolic murmur loudest at the LLSB that increased with inspiration. Lab work revealed urinary 5-HIAA was 212 (nl < 6mg/24 hours). TTE showed moderately dilated RV and severely dilated RA. Furthermore, there was a thickened, calcified and retracted TV with severe TR which was consistent with carcinoid heart disease. She was treated with diuretics and was continued on systemic therapies to help achieve control of her NET before surgical intervention for her valvular disease was considered.
Case Media
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A. ECGB. TTE: CW Doppler through tricuspid valve
Carcinoid - TTE 1
Carcinoid - TTE 2
Carcinoid - TTE 3
Carcinoid - TTE 4
Carcinoid - TTE 5
Carcinoid - TTE 6
Carcinoid - TTE 7
Carcinoid - TTE 8
Carcinoid - TTE 9
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
The patient had an NET history and presented with shortness of breath. Under what circumstances do patients with NETs present with cardiac symptoms? Amongst patients with neuroendocrine tumors (NETs), carcinoid tumors refer classically to gastrointestinal NETs. Around 30 to 40% of these patients will presents with features of carcinoid syndrome,
76. Case Report: Ehlers Danlos Syndrome with Postpartum Papillary Muscle Rupture – Cleveland Clinic
Oct 27, 2020
75. Case Report: Coronary Vasospasm Presenting as STEMI – UCSF
Oct 23, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join UCSF cardiology fellows (Emily Cedarbaum, Matt Durstenfeld, and Ben Kelemen) for some fun in San Francisco! They discuss a informative case of ST-segment elevation (STEMI) due to coronary vasospasm. Dr. Binh An Phan provides the E-CPR and program director Dr. Atif Qasim provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-50s with alcohol use disorder, cirrhosis, atrial fibrillation, and alpha thalassemia complicated by iron overload presented with hematemesis. He was tachycardic and hypotensive. Labs were notable for Hgb 8.1 (baseline of 10.2), INR 1.3, lactate 4.2, and ferritin 4660. He was started on IV PPI and octreotide. Course was complicated initially by Afib with RVR with hypotension. Subsequently, the patient developed unstable VT requiring CPR. Post-code EKG showed inferolateral ST elevations. Troponin-I rose from 19 to 225 and his pressor requirement continued to increase despite resolution of his GIB. TTE showed LVEF 42% with new inferolateral wall motion abnormalities, normal RV systolic function, severe mitral regurgitation, and small pericardial effusion. After treatment of his GIB by IR and GI, he underwent an urgent LHC which showed 30% stenosis in proximal LAD, 70% in LADD2, and 95% in distal RCA. Coronary spasm was noted in all vessels. Intracoronary nitroglycerin and nicardipine were administered with significant improvement in spasm and resolution of STE on EKG. Vasopressors were quickly weaned off after. He was eventually stabilized, extubated, and started on an oral nitrate and calcium channel blocker. Repeat TTE showed normalized systolic function without any wall motion abnormalities.
Case Media
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A. Baseline ECG - atrial fibrillationB. ECG with inferior STEMI
CORS - left system
CORS- RCA pre-vasodilator
CORS- RCA post-vasodilator
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What are the cardiac manifestations of hemochromatosis? Cardiac hemochromatosis encompasses cardiac dysfunction from either primary or secondary hemochromatosis. Initially, hemochromatosis leads to diastolic dysfunction and arrhythmias. In later stages, it can lead to dilated cardiomyopathy. Diagnosis of iron overload is established by elevated transferrin saturation (>55%) and elevated serum ferritin (>300 ng/mL). Genetic testing for mutations in the HFE gene should ...
74. Case Report: Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) – Summa Health
Oct 22, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Summa Health cardiology fellows (Jack Hornick, Phoo Pwint Nandar, and Sideris Facaros) for a hike on the Towpath Trail at Cuyahoga Valley National Park in Akron, Ohio! They discuss an informative case of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) complicated by ventricular tachycardia & cardiogenic shock. Dr. Kenneth Varian provides the E-CPR and program director, Dr. Marc Penn provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A female in her 40s with no past medical history presented 6 years prior with acute onset dizziness, palpitations and fatigue without chest pain. She had no family history of arrythmias, SCD, or prior syncope. Her heart rate was 170 bpm and EKG showed wide complex, regular tachycardia felt to be VT. She underwent synchronized cardioversion to sinus rhythm. Her baseline EKG showed sinus bradycardia with low voltage, incomplete RBBB, and ventricular ectopy. Labs were unrevealing, and social history was negative for toxic insults or illicit substance abuse. TTE showed preserved LVEF and normal valves, but RV was dilated with decreased systolic function. LHC was without obstructive coronary disease. She was diagnosed with ARVC and received an ICD for secondary prevention. She was discharged on sotalol for arrythmia management. Her genetic testing later returned positive for uncertain significance in the DSP gene and JUP gene, both commonly implicated in ARVC. She was followed in the outpatient setting for 5 years with no apparent shocks. Six years later, she presented with acute onset dizziness and palpitations similar to her initial presentation. EKG showed a wide complex tachycardia at 170 bpm treated with amiodarone and cardioversion. On ICD interrogation, she was found to have had several episodes of VT, but at a rates below the VT detection zone programmed in the ICD. Subsequent RHC showed significantly depressed cardiac index and RV dysfunction. She underwent successful inpatient VT ablation. She was then discharged home with plans for close follow up; however, 2 days later, she started feeling nauseous with fatigue and abdominal pain. She was sent straight to the nearest transplant-capable hospital where she was found to be in cardiogenic shock. She was admitted to ICU and started on inotropes. Due to refractory shock, she was cannulated for VA ECMO and successfully underwent cardiac transplantation two days later.
Case Media
123Click to Enlarge
A. Post cardioversion ECG: NSR, low voltage, incomplete RBBB, PVCB. TTE: RV enlargement C. TTE: Tissue Doppler velocity (S') low
TEE
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
What is ARVC?
Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D) is a heritable cardiac muscle disorder that classically involves the RV (though LV involvement is increasingly being recognized) marked by loss of healthy myocardium and replacement with fibrofatty tissue predominantly due to genetic defects in both desmosomal and non-desmosomal proteins. Clinical manifestations include RV dysfunction, ventricular arrhythmias, and sudden cardiac death (SCD). This is a progressive disease that can affect the epicardium and/or mid-myocardium first and then move towards the sub-endocardium. It affects approximately 1 in 5000 individuals and is an important cause of (SCD) in young patients.
73. Case Report: Wet Beriberi & Stiff Left Atrial Syndrome – Scripps Clinic
Oct 20, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Scripps cardiology fellows (Christine Shen and Andrew Cheng) for some Cardiology and California Burritos in San Diego! They discuss an informative case of Wet Beriberi and Stiff Left Atrial Syndrome. Dr. Thomas Heywood provides the E-CPR and program director Dr. Malhar Patel provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her mid-60s with history of rheumatic mitral stenosis s/p mechanical mitral valve replacement, HFpEF, and paroxysmal atrial fibrillation s/p ablation presents with subacute worsening dyspnea despite escalating diuretic doses. TTE shows an EF of 62%, normal gradients across the mitral valve without mitral regurgitation, and a dilated IVC. She is admitted with a presumed diagnosis of decompensated heart failure, and started given IV furosemide. Her symptoms slightly improve though do not resolve, and her creatinine increases from 1.4 to 2.1.
In light of the unclear hemodynamic picture, a RHC is done, showing a RA pressure 9, RV pressure of 80/10, PAP 70/25 with mPAP 40, PCWP 30, SVR 872, CO 11 (by thermodilution), and CI 5.2. Notably, large V waves are noted on the RHC. Given concern for mitral regurgitation in the setting of large V waves, a TEE was pursued, which confirmed the lack of MR seen on TTE. Thus, her large V waves were felt to be due to stiff left atrial syndrome, and a cardiac CT showed a severely calcified "coconut left atrium". Labwork revealed a profoundly low thiamine level (21, with LLN of 70), raising concern for wet beri beri syndrome.
The patient's unifying diagnosis was indolent left atrial syndrome that was exacerbated by high outout heart failure due to Wet Beri Beri syndrome. The patient received thiamine supplementation, and was diuresed to euvolemia with dramatic improvement in symptoms. A repeat RHC after thiamine replacement showed a CO of 5.7 and CI of 2.74 by thermodilution, demonstrating resolution of her high output heart failure.
Case Media
ABCDEFClick to Enlarge
A. CXRB. ECGC. RHC: large V waves are noted on the RHCD. CO 11 and CI 5.2 by thermodilution pre-treatment E. Cardiac CT showed a severely calcified "coconut left atrium"F. Repeat CO of 5.7 and CI of 2.74 by thermodilution after thiamine replacement
TTE 1
TTE 2
TEE 1 - Mitral Valve
TEE 2 - Mitral Valve
Cardiac CT
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
72. Case Report: Effusive Constrictive Pericarditis – University Hospitals Case Western
Oct 19, 2020
CardioNerds (Amit Goyal & Karan Desai) join University Hospitals Cleveland Medical Center cardiology fellows (Tarek Chami, Jamal Hajjari, and Haytham Mously) for some amazing pizza and coffee in Cleveland, Ohio! They discuss an important case of effusive constrictive pericarditis. Dr. Brian Hoit provides the E-CPR and assistant program director Dr. Claire Sullivan provides a message for applicants. We are grateful to chief fellow Scott Janus for his leadership in planning this episode! Episode notes were developed by Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her mid-70s presented to clinic with subacute onset shortness of breath. Her past medical history includes metastatic breast cancer s/p mastectomy, chemo/radiation, and hormonal therapy. Exam notable for tachycardia without hypoxia, muffled heart sounds, JVD with Kussmaul's sign, and 1+ LE edema. The patient was sent to the ED for evaluation of possible pericardial effusion. CTA chest in ED did not demonstrate a PE, but did show bilateral pleural effusions, and a moderate pericardial effusion with evidence of metastatic disease extending into the mediastinum. TTE obtained showing normal LVEF, moderate pericardial effusion with thickened pericardium, and significant respirophasic tricuspid and mitral inflow variations. Pulsus paradoxus was manually checked and found to be 16 mmHg.
Due to concern for cardiac tamponade, she was taken to the cath lab for a RHC and pericardiocentesis. RHC prior to pericardiocentesis showed elevated left and ride sided filling pressures, blunted y decent in the RA, and equalization of diastolic pressures. Pericardiocentesis yielded 200 cc of bloody fluid with improvement, but continued elevation, in her L and R sided pressures. Blunted y decent did give way to a now rapid y descent concerning for constrictive pericarditis. She then underwent a cardiac MRI showing respirophasic septal motion suggestive of interventricular dependence and >1 cm thick pericardium with LGE c/w inflammation. Unfortunately, cytology of pericardial fluid was c/w a malignant effusion and despite treatment with a few months of anti-inflammatory therapy her symptoms did not improve. She then underwent a pericardial stripping with subsequent resolution of her symptoms. As her symptoms and hemodynamics were related to both the effusion and constriction, she was ultimately diagnosed with effusive constrictive pericarditis.
Case Media
ABCDEFGHIJKLMNOClick to Enlarge
A. ECGB. CXRC-F. TTE (inflow velocities (mitral and tricuspid),
71. Case Report: Post-MI Ventricular Septal Rupture – University of Michigan
Oct 14, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Michigan cardiology fellows (Apu Chakrabarti, Jessica Guidi, and Amrish Deshmukh) for some craft brews in Ann Arbor! They discuss a challenging case of Ventricular Septal Rupture after acute MI. Dr. Kim Eagle, editor of ACC.org & host of Eagle's Eye View Podcast, and Dr. Devraj Sukul provide the E-CPR and message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A male in his 60s with medical history of obesity and GERD presents with five days of progressive chest pressure radiating to bilateral arms and associated with dyspnea on exertion. Due to worsening chest pain with new lightheadedness, he decided to come to the ED. His presentation to the hospital was delayed due to fear of contracting COVID-19. In the ED, patient was afebrile, blood pressure 96/56, HR 137, RR 22, and oxygen saturation 94% on room air. On exam, he was ill appearing, acutely distressed, and altered. He had a 3/6 mid systolic murmur loudest at L sternal border, JVP to 10 cm H2O and had crackles up to mid-lung fields. His extremities were cool to touch. Labs notable for Cr 1.5, High-Sensitivity Troponin-T up to 5756, and lactate 3.9. EKG showed incomplete RBBB, PVCs, and ST elevations in the inferior leads with depressions in lateral and precordial leads. Coronary Angiography showed mid-RCA occlusion with faint L to right collaterals. He underwent PCI with restoration of TIMI 3 flow. After PCI, he continued to be hypotensive requiring IABP and norepinephrine. PA catheter demonstrated (in mmHg): RA 26, RV 63/29 (31), 55/36 (44), PCWP 29, and CO 5 L/min, CI 2.2, and SVR 467. Shunt run of mixed venous O2 saturation showed: SVC 71%, RA 72%, RV 62%, PA 85% with oxygen step up in the R-sided circuit. Left ventriculogram then confirmed septal rupture with contrast extravasation from LV into RV. Due to worsening shock, he was stabilized on VA ECMO which was complicated by hemolysis and acute renal failure requiring CVVHD. On day 7 after presentation, he underwent surgery which revealed a large 6x6 cm ventricular septal defect on the posterior aspect of the septum and repaired with a large bovine pericardial path. He was eventually discharged after a prolonged stay and repeat TTE on follow up showed biventricular dysfunction and residual 1cm VSD.
Case Media
ABCDClick to Enlarge
A. ECG: Incomplete RBBB, PVCs, and ST elevations in the inferior leads with depressions in lateral and precordial leads. B. Coronary angiography: mid-RCA occlusion with faint ...
70. Case Report: Post-MI Free Wall Rupture & Pseudoaneurysm – UCONN
Oct 13, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Connecticut (UCONN) cardiology fellows (Mansour Almnajam, Justice Oranefo, Yasir Adeel, and Srinivas Nadadur) as they enjoy the amazing view from the Heublein tower! They discuss a challenging case of left ventricular free wall rupture & pseudoaneurysm as a complication of a STEMI. Dr. Peter Robinson provides the E-CPR and program director Dr. Joyce Meng provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid 50s with no significant PMH presented with a 10-day history of chest pain that progressed to acute pleuritic pain and shortness of breath in the past 24 hours. On arrival, he was hypothermic, in rapid atrial fibrillation with HR in the 130-150s, and an initial BP was not able to be obtained. He was tachypneic with labored breathing, lethargic, and cyanotic. Exam revealed markedly elevated JVP, cool extremities, and diminished breath sounds with bibasilar rales. Labs demonstrated leukocytosis, significantly elevated liver enzymes, troponin-I at 10.91, elevated NT-proBNP, and lactate at 6. ECG demonstrated tall, broad R-waves in V1-V4 with downsloping STD and upright T-waves concerning for a posterior infarct. He was immediately intubated, cardioverted into NSR, and started on vasopressors. Bedside echocardiogram demonstrated diffuse LV hypokinesis with akinesis of the inferolateral wall, LVEF 25-30%, and pericardial fluid with hyperechoic material adherent to the inferior wall as well as tamponade physiology. Chest CTA was negative for aortic dissection and confirmed hemopericardium. He was taken to the OR where he underwent a subxiphoid pericardial window. They found significant clot burden (both old and new), but no frank rupture. Adherent clot was not removed to prevent further hemodynamic compromise. Intraoperative TEE additionally demonstrated severe eccentric MR with partial posteromedial papillary muscle rupture. An IABP was placed and inotropic and vasoactive support was continued to temporize pending definitive therapy and the patient improved hemodynamically. Repeat TTE prior to surgery demonstrated a large apical and inferolateral pseudoaneurysm. Coronary angiogram revealed proximal occlusion of the LCx and diffuse three vessel coronary disease otherwise. He ultimately underwent CABG, mechanical mitral valve replacement, and pericardial patch repair of the ventricular pseudoaneurysm. Final diagnosis: Free Wall Rupture & Pseudoaneurysm. Thankfully,
69. Case Report: Cardiac Allograft Vasculopathy (CAV) – UCSD
Oct 13, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of California San Diego (UCSD) cardiology fellows (Harpreet Bhatia, Dan Mangels, and Quan Bui) for a relaxing beach bonfire in the beautiful city of San Diego! They discuss a challenging case of post-transplant cardiac allograft vasculopathy. Dr. Hao (Howie) Tran provides the E-CPR and program director Dr. Daniel Blanchard provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his late 20s with a past medical history of orthotopic heart transplant, presents with one-week of progressive lower extremity edema and dyspnea with NYHA class IV symptoms. 5 years prior, he underwent orthotopic heart transplant for arrhythmogenic right ventricular cardiomyopathy. Subsequently, he has had multiple episodes of rejection or recurrent graft dysfunction. On presentation, he was normotensive and borderline tachycardic. Exam revealed elevated JVP, decreased breath sounds, and pitting edema. Labs demonstrated leukocytosis, acute kidney injury, and elevated pro-BNP. TTE demonstrated LVEF 35%, apical akinesis, and grade III diastolic dysfunction (all similar to prior). He was initially diuresed and RHC/EMB was performed to evaluate for rejection. Early in his course, the patient unfortunately suffered a PEA arrest with ROSC was quickly achieved after 1 minute of CPR. He was intubated and cannulated for VA ECMO. EMB demonstrated ISHLT Grade 1R cellular rejection and he was ultimately listed for re-transplant. Shortly thereafter, the patient received an OHT. His pathology demonstrated intimal thickening of all his coronaries, consistent with coronary artery vasculopathy, felt to be the major contributor to his presentation.
Case Media
ECG
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. What is CAV?
CAV stands for cardiac allograft vasculopathy. Within the transplanted heart, CAV is the proliferation of vascular smooth muscle and intimal thickening in the epicardial coronary arteries and microvasculature leading to diffuse narrowing. CAV is common, present in greater than 30% of patients at 5 years post-transplant. It is a significant contributor to post-transplant mortality after the first year. CAV, in contrast to typical atherosclerotic lesions, is diffuse and concentric while atherosclerosis tends to be focal with eccentric luminal narrowing and heterogenous plaque composition. Patients s/p OHT can still develop typical coronary artery disease,
68. Case Report: WPW and HCM Phenotype – VCU
Oct 09, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Virginia Commonwealth University (VCU) cardiology fellows (Ajay Pillai, Amar Doshi, and Anna Tomdio) for a delicious skillet breakfast and amazing day in Richmond, VA! They discuss a fascinating case of a patient with Wolff-Parkinson-White (WPW) and hypertrophic cardiomyopathy (HCM). Dr. Keyur Shah provides the E-CPR and program director Dr. Gautham Kalahasty provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-60s presented to the ED after an episode of unwitnessed syncope while drinking. Patient had suddenly passed out from a seated position with no prodrome or post-ictal state. He had episodes like this in the past, which were thought to be seizures, but otherwise PMHx only notable for alcohol use disorder. He denied any FH of SCD or syncope. In the ED, exam was unremarkable. Labs notable for mild thrombocytopenia, mild hyponatremia with AKI, 2:1 AST/ALT ratio, elevated NT-proBNP, and a very high lactate that rapidly corrected with fluids. EKG was notable for sinus tachycardia, short PR interval, wide QRS, and delta waves consistent with Wolff-Parkinson-White (WPW) pattern. Echo showed preserved LVEF, thickened LV septum (1.6 cm) and posterior wall (1.3 cm) concerning for hypertrophic cardiomyopathy (HCM). No outflow tract gradient was noted at rest or with stress, and the strain pattern demonstrated apical sparing. Evaluation for cardiac amyloid, including plasma cell dyscrasia and PYP scan, was negative. Cardiac MRI confirmed severely thickened LV inferior and inferolateral walls at 1.7 cm with no LVOT obstruction. 25% of the myocardium demonstrated patchy LGE.
Due to concern for WPW syndrome, the patient underwent an EP study. This revealed a malignant septal accessory pathway that was successfully ablated with resolution of the WPW EKG features. Given large LGE burden in setting of HCM, patient underwent placement of primary prevention ICD. Genetic testing for PRKAG2 mutation is pending given comorbid WPW and HCM.
Case Media
AECDBFClick to Enlarge
A. CXR: Slightly increased interstitial markings in the lung bases, an elevated right hemidiaphragm. No acute airspace disease or pulmonary edemaB. ECG: Sinus tachycardia rate 120bpm, PR interval 80ms, QRS 130ms, WPW pattern. Arruda algorithm localizes to posterior septum.C. CMR: Myocardium nulls before blood pool.D. CMR: Delayed gadolinium enhancementE. Follow up ECG: NSR 78, repolarization abnormalities. T wave memory inferior leads.F.
67. Case Report: STEMI after EVALI Diagnosis – Baylor College of Medicine
Oct 09, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Baylor College of Medicine cardiology fellows (Khurrum Khan, John Suffredini, and Aliza Hussain) during restaurant week in Houston! They discuss an interesting case of STEMI in a patient with a recent diagnosis of e-cigarette or vaping product use-associated lung injury (EVALI). Dr. Vijay Nambi provides the E-CPR and APD Dr. Arunima Misra provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A male in his mid 40s with a 30 pack year smoking history, EVALI (e-cigarette and vaping associated lung injury), and asthma presented with dyspnea and persistent chest pain. He had been vaping for the past year. One month prior , CT chest showed bilateral patchy infiltrates and he was diagnosed with EVALI and started on a steroid taper with resolution of his CT abnormalities. A nuclear stress test at that time was negative for ischemia. On arrival, he was in sinus tachycardia, normotensive, and not on oxygen supplementation. Physical exam was negative for volume overload or heart murmurs. EKG showed new Q waves with STE in V2-V4, with associated Q waves and TWI in the lateral leads and troponin returned moderately elevated. He was emergently taken to the cath lab which showed an abrupt cutoff of flow to the LAD. He received a single DES with resolution of coronary flow. A post-cath TTE showed an LVEF of 40-45% with apical anterior and anteroseptal WMA. He was monitored in the CCU the next day and he was treated with aspirin, ticagrelor, ACEi, metoprolol succinate and high intensity statin and subsequently discharged in stable condition with cardiac rehab follow-up.
Case Media
ABClick to Enlarge
A. Presentation ECG (Anterior STEMI) B. Baseline ECG
LAD occlusion
Post PCI
RCA
TTE 1
TTE 2
TTE 3
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. The patient presented with a STEMI following a diagnosis of EVALI. What is known about the cardiovascular risks of vaping and e-cigarette use?
The overall cardiovascular risks of e-cigarette use remains to be elucidated In preclinical studies, e-cigarettes use have been linked to increased sympathetic activity, oxidative stress, endothelial dysfunction, vascular injury, and altered platelet activity One observational study has suggested that daily e-cigarette users were 1.79 times more likely to experience MI than individuals who had never used e-cigarettes.
66. Case Report: Severe Pre-eclampsia & Cardio-Obstetrics – UPMC
Oct 06, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Pittsburgh Medical Center cardiology fellows (Agnes Koczo, Natalie Stokes, and Kayle Shapero) for a boat cruise down the Allegheny river as we tour all over beautiful Pittsburgh! They discuss an important case of severe pre-eclampsia, and explore some of the exciting dimensions of cardio-obstetrics. Dr. Malamo Eleni Countouris provides the E-CPR and program director Dr. Katie Berlacher provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A G12P7 woman in her mid 30s in the third trimester of pregnancy presented with two months of progressive shortness of breath, orthopnea, and abdominal distension. She has a history of chronic HTN, untreated OSA, and obesity. Evaluation revealed a BP of 147/76 and spot urine protein:creatinine ratio elevated to 0.6, which in the context of her presentation was concerning for preeclampsia superimposed on chronic hypertension. TTE showed preserved ejection fraction, flattened interventricular septum during systole consistent with RV pressure overload, and moderate pulmonary HTN.
She was diuresed with IV furosemide with improvement in symptoms and kept on ASA 81mg. The etiology of her elevated PA pressures was thought to be multifactorial, including untreated OSA for which she was started on CPAP. She was ultimately discharged on oral diuretics, and underwent an uncomplicated spontaneous vaginal delivery at 37 weeks. After delivery, follow-up in a clinic specializing in improving cardiovascular health in women with history of hypertensive disorders of pregnancy was arranged.
Case Media
ABCClick to Enlarge
A. ECG: Sinus tachycardia otherwise unremarkableB. CXR: Within limitations of respiratory motion, no focal airspace consolidation; no pleural effusionsC. TTE: EF 55-60%, flattened IVS c/w RV pressure overload; normal RV size and function; mod TR; moderate pulmonary HTN (PASP 52mmHG); normal diastolic function
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. Cardionerds, we all should be familiar with #CardioObstetrics. What are the hypertensive disorders of pregnancy?
There are four major categories for hypertensive disorders in pregnancy: (1) chronic hypertension (2) gestational hypertension; (3) preeclampsia (along with eclampsia and HELLP syndrome); (4) chronic hypertension with superimposed preeclampsia. Chronic Hypertension: Note,
65. Case Report: Spontaneous Coronary Artery Dissection (SCAD) Requiring Heart Transplantation – UCLA
Oct 05, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join join UCLA cardiology fellows (Jay Patel, Hillary Shapiro, and Ruth Hsiao) for some beach bonfire in Santa Monica! They discuss a challenging case of Spontaneous Coronary Artery Dissection (SCAD) requiring heart transplantation. Dr. Jonathan Tobis provides the E-CPR and program director Dr. Karol Watson provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her late 40s presented with a one day history of intermittent chest pain. EKG showed anteroseptal and lateral STE with reciprocal ST depressions in the inferior leads. High-sensitivity troponin was elevated at 333 ng/mL. Emergent LHC showed a long and narrow left main with areas of additional contrast filling into a false lumen with no flow in the LAD. RCA and LCx were normal appearing (make sure you check out the angiogram videos below!). IVUS showed dissection and heavy thrombus burden in the left main artery. Shortly after the diagnostic angiogram, the patient went into V-fib arrest and received one shock with ROSC. Amiodarone was started and an Impella CP was placed for additional left ventricular support. ECMO and emergent CABG were not readily available at this time so the interventional team attempted revascularization with PCI to the left main given patient's hemodynamic instability from ongoing ischemia. However, even after PCI to left main, flow to LAD remained poor and the LCx now also appeared occluded. The decision was made to cease further attempts at revascularization. Unfortunately, post-procedure TTE showed a reduced EF of 22% with anterior and anterolateral hypokinesis. She was transferred to CCU on maximal Impella support. Patient eventually developed acute renal and liver failure secondary to cardiogenic shock and suffered an additional V-fib arrest with ROSC. Eventually, Ronald Reagan UCLA was contacted for transfer and the mobile ECMO team was dispatched. They placed the patient on VA-ECMO in the outside facility and transferred her to Ronald Reagan UCLA. At Ronald Reagan, revascularization was attempted given persistent cardiogenic shock and 3 stents were successfully deployed in the LAD. She was eventually weaned off of both Impella and ECMO after successful PCIs to LAD. However, TTE showed persistently low EF and patient eventually underwent successful heart-kidney transplantation.
Case Media
ABCDClick to Enlarge
A. ECG: Anterior STE, STE in I/aVL but depressedions in V4-V6, inferior reciprocal ST depressionB.
64. Case Report: RV Infarction Treated with RVAD Support – Houston Methodist
Oct 02, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Houston Methodist cardiology fellows (Isaac Tea, Stephanie Fuentes, Peter Rothstein) for a trip to Hermann Park! They discuss a challenging case of right ventricular (RV) infarction leading to acute RV failure treated with right ventricular assist device (RVAD) support. Dr. Mahwash Kassi provides the E-CPR and program director Dr. Stephen Little provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his early 70s with ASCVD risk factors and known CAD (PCI to proximal LAD 4 years prior) presented with typical angina refractory to maximal medical therapy. A nuclear stress test showed a reversible perfusion defect in the RCA territory, and he was referred for PCI. Coronary angiogram showed severe stenosis of the proximal RCA and a DES was successfully deployed with TIMI 3 flow, though several large acute marginal branches were jailed.
The night following PCI, the patient developed bradycardia, hypotension, and tachypnea. Physical exam showed newly elevated JVP, lower extremity edema, and bibasilar crackles without a new cardiac murmur. ECG showed ST elevation in V1-V4, and bedside echocardiogram showed a severely dilated RV with decreased systolic function. With concern for acute RV failure, the patient was fluid resuscitated, started on dopamine for chronotropy, and was admitted to the CCU. A Swan-Ganz catheter was placed, showing a CVP 12, RV 41/15, PA 36/20 (25), PCWP 18, CI 1.6 (by Fick method). The calculated PAPi was 0.84.
The patient was transitioned to dobutamine to improve RV inotropy, epinephrine in the setting of hypotension, and inhaled nitric oxide in an attempt to decrease RV afterload. Despite these interventions, the patient had worsening shock, anuric renal failure requiring CVVH, and respiratory failure requiring intubation. A centrifugal RA to PA pump was placed (Protek Duo) for right-sided mechanical circulatory support, with improvement in RV hemodynamics and cardiogenic shock. Notably, a repeat angiogram was done, which showed a patent left coronary circulation as well as a right coronary artery without flow in the acute marginal branches. After 6 days of mechanical circulatory support, the patient was ultimately able to be weaned from vasoactive agents, and the Protek Duo was removed. He continued to have junctional bradycardia, and a permanent pacemaker was placed. After a nearly month-long admission, the patient was discharged to rehab; at 4 months follow-up,
63. Case Report: Peripheral Artery Disease (PAD) & Cerebral Hyperperfusion Syndrome – University of Florida
Sep 30, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join University of Florida cardiology fellows (Ashley Mohadjer, Hussain Khalid, and Morgan Randall) for an authentic Gainesville-style tailgate! They discuss a fascinating case of severe peripheral artery disease (PAD) and cerebral hyperperfusion syndrome. Dr. Khanjan Shah provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her 60s with a past medical history of type 2 diabetes, hypertension, and hypothyroidism presented to the University of Florida with a chief complaint of "Someone told me my neck artery was blocked." Someone call 227-346-6373. What does that spell? CardioNerd!
She noted exertional pain in both legs with limited exertion. Has a family history of CAD and MI in her father in his 20s. Her only medications were baby aspirin, atorvastatin 80mg, and thyroid replacement. Her blood pressures were noted to be dropping and so her regimen was being titrated off as a result. Physical exam was notable only for poorly palpable pulses in all extremities. To further work this up, a myocardial perfusion scan, CTA head/neck/abdomen, and ABIs were ordered. ABI on the right was 0.86 and on the left was 0.76 with monophasic doppler waveforms throughout. CT abdomen exhibited an occlusion of the abdominal aorta from just below the renal arteries extending to the common iliac arteries with distal reconstitution. CT head/neck showed occlusion of the right carotid artery, complete occlusion of the right innominate artery, near complete occlusion of the right vertebral artery, and delayed flow in the right posterior cerebral artery. On the left side, she had high-grade subclavian stenosis. Myocardial perfusion imaging exhibited no defects.
On subsequent visits her exercise tolerance improved with an exercise regimen, but blood pressures were more and more difficult to obtain. As a result, revascularization was pursued with stenting of the left subclavian artery. She was discharged, but returned a few hours later with severe left sided pulsatile headache and nausea/vomiting. She was admitted for monitoring, but fortunately improved and discharged with close outpatient follow-up. She continued to improve in the outpatient setting. After MRI brain and extensive work-up, she was deemed to have cerebral hyperperfusion syndrome following revascularization. She had no further complications and was monitored thereafter. Final diagnosis: severe peripheral artery disease (PAD) and cerebral hyperperfusion sy...
62. Case Report: RV Failure & Shock After placement of an AV graft – The Johns Hopkins Hospital
Sep 27, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Johns Hopkins Hospital cardiology fellows (Rick Vakil, Pranoti Hiremath, and Vasanth Sathiyakumar) for some gelato by the bay in Baltimore, Maryland! They discuss a challenging case of RV failure & shock after placement of an AV graft. Dr. Monica Mukherjee provides the E-CPR and program director Dr. Steven Schulman provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his early 40s, with a history of type 1 diabetes and prior failed renal and pancreatic transplants currently on iHD, was referred to Johns Hopkins Hospital for dialysis access. A left groin AV loop graft was pursued due to multiple access point failures in the past secondary to severe peripheral artery disease. Pre-op evaluation included risk stratification with RHC which was consistent with WHO Group 2 pulmonary HTN and diffuse atherosclerosis in the RCA on LHC. Intra-op, patient had an episode of significant hypotension after administration of protamine that required phenylephrine and ephedrine. In the PACU, his BPs continued to be low (70s/40s mmHg), requiring admission to the SICU where cardiology was consulted.
In the SICU, patient had ongoing hypotension despite pressors and fluids. Exam demonstrated a systolic murmur consistent with TR and elevated JVP. Labs were notable for a mild elevation in liver enzymes, elevated troponin, high NT-proBNP and elevated lactate. TTE demonstrated a moderately dilated and hypokinetic RV, elevated RVSP and evidence of pressure/volume overload. CTA abdomen/pelvis demonstrated extensive mesenteric atherosclerosis and signs of gastric ischemia. Patient was treated for RV failure with norepinephrine, inhaled epoprostenol, and CVVHD for volume removal. He became febrile and was treated empirically with broad spectrum antibiotics. Due to concern for the new loop graft causing high output heart failure vs RV failure, it was temporarily occluded for testing and then permanently ligated by vascular surgery with significant improvement in his BPs and RV function on repeat TTE.
Case Media
ABCDEClick to Enlarge
A. Plato's allegory of the cave by Jan Saenredam, according to Cornelis van Haarlem, 1604, Albertina, ViennaB-C. Anesthesia flow sheets D. CXR: Pulmonary vascular congestion, bibasilar atelectasisE. ECG: Sinus tachycardia to 110, RAD, RBBB, similar to prior
TTE: LVEF 60-65%, mild to moderate concentric hypertrophy, trace effusion
TTE: Flattened septum in systole and diastole c/f RV pressur...
61. Case Report: Cardiac Arrest due to Peripartum Cardiomyopathy – Medical College of Wisconsin
Sep 25, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Medical College of Wisconsin cardiology fellows (Katie Cohen, Div Mohananey, and Dave Lewandowski) for some cold brews by Lake Michigan in Cream City aka Milwaukee, WI! They discuss a case of a pregnant woman presenting cardiac arrest due to peripartum cardiomyopathy. Dr. Sarah Thordsen provides the E-CPR and program director, Dr. Nunzio Gaglianello, provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A G2P1 woman in her early 30s with a history palpitations presented after a witnessed out-of-hospital cardiac arrest while at work. She received 6 rounds of CPR and 2 shocks before ROSC was achieved. She was intubated and given fluids but continued to remain hypoxic and hypotensive. Exam demonstrated sinus tachycardia, no murmurs, gravid abdomen and cool extremities. Initial labs demonstrated leukocytosis to 14k, lactic acid at 4.3 mmol/L, troponin-I peak at 0.07 ng/dL and elevated NT-proBNP. CXR demonstrated bilateral effusions and pulmonary congestion, and post-arrest EKG showed a wide complex tachycardia, leading to suspicion of VT arrest. In sinus, there were no ST segment elevations and TTE showed LVEF 10-20%, global hypokinesis and no valvular disease. Given the severity of her shock, she was placed on central VA-ECMO with Impella support as an LV vent. During ECMO cannulation, she underwent emergent cesarean section due to fetal distress. Coronary angiography showed non-obstructive coronaries, but with sluggish flow in the setting of her cardiogenic shock and possible coronary spasm in setting of multiple vasoactive medications. Endomyocardial biopsy was negative for giant cell myocarditis. Within 4-5 days, she was weaned off all vasoactive agents and ECMO was decannulated; repeat echocardiogram showed LV functional recovery. GDMT was slowly titrated and a subcutaneous ICD was eventually placed before discharge. She and her child have done well over the course of a year!
Case Media
ABClick to Enlarge
A: ECG: Initially in sustained wide complex irregular tachycardiaB: CXR: Extensive consolidative changes throughout the lungs
TTE: Parasternal Long Axis
TTE: Apical 4 Chamber
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. What is the differential for cardiac arrest in pregnant patients?
When thinking about a cardiac etiology of arrest, the differential should include pregnancy-induced hypertension,
60. Case Report: Massive Pulmonary Embolus Presenting as STEMI – Cedars-Sinai
Sep 23, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Cedars-Sinai cardiology fellows (Natasha Cuk, Ronit Zadikany, Neal Yuan) for some drinks at the local pub 3rd Stop after a walk down Hollywood boulevard! They discuss a fascinating case of a massive pulmonary embolus presenting as STEMI. Dr. Babak Azarbal provides the E-CPR and program director Dr. Joshua Goldhaber provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his mid-40s with no known past medical history presented to the ER in PEA arrest with ongoing cardiopulmonary resuscitation (CPR). Prior to his arrest, his coworkers reported that he was complaining of lightheadedness, dizziness and that he was found slumped over at his desk. His EKG in the ambulance showed STE in aVR and V1 - V4 with TWI in III and aVF initially concerning for an anterior STEMI. He was cannulated with VA-ECMO for extracorporeal cardiopulmonary resuscitation (E-CPR) and was taken to the catheterization lab emergently. In the catheterization lab, his coronary angiogram did not show obstructive coronary disease. The interventionalists decided to perform a pulmonary artery (PA) angiogram which revealed a large amount of thrombus bilaterally in the proximal PAs. He underwent surgical embolectomy with removal of almost all his clot burden. The patient was thereafter cooled for neurological protection. Unfortunately, the patient had a very poor neurological exam with lack of brainstem reflexes upon rewarming. There was loss of gray-white differentiation on CT, and EEG and evoked potential testing were consistent with severe anoxic brain injury. After discussions with the patient's family, the patient was transitioned to comfort care and subsequently passed away peacefully.
Case Media
Click to Enlarge
Right Coronary Artery
Left Coronary System - 1
Left Coronary System - 2
Left Pulmonary Artery
Right Pulmonary Artery
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
The patient presented initially with STE in aVR as well as the septal and anterior leads. What is the differential for an ST elevation in lead aVR? STE in aVR with diffuse ST depression can be a potential finding of LM or LAD stenosis. However, there have been several studies that have shown that the combination of STE and multi-lead STD was not associated with complete occlusion of a culprit vessel. Thus,
59. Case Report: Constrictive Pericarditis & Severe Mitral Regurgitation – Mayo Clinic
Sep 21, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join join Mayo Clinic cardiology fellows (Mays Ali, Charlie Jain, Korosh Sharain) for a scenic walk through gorgeous Rochester, Minnesota! They discuss a fascinating case of constrictive pericarditis and severe mitral regurgitation. Dr. Rick Nishimura provides the E-CPR and program director Dr. Frank Brozovich provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Bibin Varghese with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Constrictive Pericarditis & Severe Mitral Regurgitation - Patient Summary
A woman in her late 40s with a history of lupus and hypertension presented with worsening dyspnea on exertion and orthopnea over a year. She reported intermittent pleuritic chest discomfort that had persisted since an episode of acute pericarditis years prior. A TTE suggested severe mitral regurgitation, and she was referred to the Mayo Clinic for mitral valve intervention.
The official TTE report from the OSH suggested non-dilated LV, EF 55-60%, normal RV function, severe MR with thickened leaflets and sub-valvular apparatus, moderate to severe TR and a dilated IVC. Furthermore, the CXR showed pericardial calcifications. Upon evaluation by the Mayo Clinic fellows, the JVP was elevated to about 10-12 cm with rapid x and y descents, a positive Kussmaul’s sign, and the murmurs of MR and TR. Her lungs were clear to auscultation and extremities did not demonstrate edema. Re-review of the TTE images revealed posterior pericardial thickening, no septal shift on respiration, but suggestion of annulus reversus where medial mitral annulus tissue doppler (9 cm/s) was greater than lateral (8 cm/s). Further, there was evidence of expiratory hepatic vein diastolic flow reversal.
For the team, there was discordance between the apparent severity of her MR reported by echocardiogram and her clinical symptoms. In addition, the echocardiogram was suggestive of specific signs of constrictive pericarditis. Thus, simultaneous RHC/LHC was obtained. There was equalization of RV/LV pressures during diastole, demonstration of a “square root sign” and importantly discordance between LV and RV pressures with respiration. Thus, discordant clinical findings led to a suspicion for constrictive pericarditis and was corroborated by discordance on invasive hemodynamics! Further, the V-waves were not prominent on wedge pressure tracing and to investigate the mitral regurgitation further, an LV ventriculogram was done. This demonstrated 3+ to 4+ MR. Based on all the findings,
58. Case Report: Constrictive Pericarditis – University of Tennessee
Sep 18, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join join University of Tennessee cardiology fellows (Rachel Goodwin, Emmanuel Isang, and William Black) for some chocolate cake and hikes in the Smoky Mountains! They discuss a fascinating case of constrictive pericarditis. Dr. Tjuan Overly provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his late 40s with a history of renal failure secondary to IgA nephropathy and now status post a kidney transplant 10-15 years ago was referred by hepatology for evaluation of recurrent ascites and LE edema. He appeared grossly volume overloaded on exam with JVP elevated past the mandible, RV heave, and 2+ pitting edema. TTE demonstrated LVEF of 55-60%, RVSP 40mmHg, abnormal septal motion with respiration, and respirophasic variation in mitral inflow across the mitral valve raising the suspicion for constrictive pericarditis. RHC pressures demonstrated a mean RA pressure of 20mmHg, RV 40/25mmHg, PA 38/30mmHg (mean 32 mmHg) and PCWP mean of 26 with V-waves at 28 mmHg. Simultaneous LV and RV pressure tracings showed ventricular discordance with respirophasic variation, consistent with constrictive physiology. Patient underwent pericardiectomy with markedly improved heart failure symptoms. Repeat TTE showed no evidence of constriction.
Case Media
ABCClick to Enlarge!
A. ECGB. Pulsed-wave Doppler spectrum of tricuspid inflow velocities demonstrates a marked respiratory variation (In irregular rhythms, such as the atrial fibrillation seen here, respirophasic changes may still be seen but are confounded by the varying R-R interval)C. Simultaneous LV and RV pressure tracings showing discordance with respirophasic variation
Apical 4-chamber view demonstrating abnormal septal motion due to interventricular dependence – dissociation of thoracic and cardiac chamber pressures leads to increased RV filling during inspiration
Short axis view of the LV demonstrating a D-shaped interventricular septum during inspiration. Note the presence of a pericardial effusion as well.
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
The initial presentation clinically seemed to be right greater than left heart failure. What are the signs and common causes of right heart failure?
The signs and symptoms of RHF are often similar to left-sided CHF, but may describe more severe dyspnea on exertion,
57. Case Report: Peripartum Cardiomyopathy with Cardiogenic Shock – University of Pennsylvania
Sep 16, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Penn cardiology fellows (Brian McCauley, Norrisa Haynes, and Mahesh Vidula) for a rooftop picnic in sunny Philadelphia! They discuss an informative case of peripartum cardiomyopathy with cardiogenic shock. Program director Dr. Frank Silvestry provides the E-CPR segment and a message to applicants. Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
Two weeks postpartum, a woman in her mid 20s, G1P1, with no past medical history presented following a tonic-clonic seizure. Prior to this, she had been experiencing 1 week of worsening dyspnea and lower extremity edema. Initial work-up revealed a left MCA stroke and she underwent thrombectomy. Limited TTE found LVEF <20% and a LV apical thrombus; she was started on milrinone due to concern for cardiogenic shock and transferred to the University of Pennsylvania.
Upon arrival, she was found to be hypotensive and tachycardic. Exam was notable for elevated JVP, +S3, LE edema and R sided hemiparesis. Labs showed multiorgan injury, elevated NT-proBNP and elevated lactate. EKG demonstrated sinus tachycardia with no ST-T changes. Formal TTE showed severely dilated LV with EF 10%, diffuse LV hypokinesis, and confirmed a large LV apical thrombus. A pulmonary artery catheter was placed for tailored therapy and found elevated L-sided > R-side filling pressures with low cardiac index despite inotropes. Cardiac power output (CPO) was severely decreased with borderline pulmonary artery pulsatility index (PAPI), corroborating left > right heart failure. Patient ultimately required a durable left ventricular assist device (LVAD). Over the course of 9 months her guideline directed medical therapy (GDMT) was titrated and her intrinsic cardiac function and symptoms improved. Her EF improved to 35-40% and she tolerated an LVAD weaning protocol, so her LVAD was ultimately explanted! She is currently doing well on GDMT alone!
Case Media
CXR: Mild interstitial edema, +ET tubeST (131), LAD, nonspec T wave flattening, nl intervalsClick to Enlarge
TTE 1
TTE 2
Episode Schematics & Teaching
Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. How do we define Peripartum Cardiomyopathy?
Diagnosis is made by the development of heart failure towards the end of pregnancy or in the months following delivery (~5 months postpartum), no other identifiable cause of HF, and demonstration of LV systolic dysfunction with LVEF typically less...
56. Case Report: Arrhythmogenic Desmoplakin Cardiomyopathy – Northwestern University Feinberg School of Medicine
Sep 14, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Northwestern University cardiology fellows (Sarah Hale, Sarah Chuzi, and Graham Lohrmann) for burgers and a great case by the Chicago River! They discuss a fascinating case of arrhythmogenic desmoplakin cardiomyopathy. Dr. Lisa Wilsbacher provides the E-CPR and program director Dr. Benjamin Freed provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A male in his early 40s presented for second opinion regarding multiple ICD shocks. 10 years prior he was diagnosed with a "weak heart," thought secondary to a viral illness and a dual-chamber ICD was placed at that time. He noted shocks occurring for the first time 5 years prior, at which time amiodarone was started. They recurred two years prior, when he was diagnosed with paroxysmal atrial fibrillation. Finally, he was hospitalized one month before presentation with multiple ICD shocks and was found to have high defibrillation thresholds (DFTs) and amiodarone was stopped. He then presented for a second opinion from the Northwestern CardioNerds!
The patient had been doing well on GDMT and had NYHA Class I symptoms (Enjoy Ep #13 - Approach to GDMT). He did note a family history of a cousin with "cardiac issues" and did not know his father's family history. Physical exam demonstrated bradycardia and ECG demonstrated an a-paced, v-sensed rhythm at 50 bpm. TTE demonstrated a moderately dilated LV with LVEF 30%, globally reduced LV function and multiple wall motion abnormalities without a vascular distribution. PET-CT was performed which showed diffuse uptake and high-intensity signal at the inferolateral and basal anterior walls. Cardiac MRI showed diffuse circumferential epicardial delayed enhancement with associated diffuse, enhancing thickening of the pericardium favoring inflammatory versus fibrotic process. Patient was initially diagnosed with cardiac sarcoid and started on prednisone and weekly methotrexate.
On return of genetic testing, patient found to have a pathogenic variant for desmoplakin gene, and it was felt his cardiomyopathy was secondary to desmoplakin Left Dominant Arrhythmogenic Cardiomyopathy (LDAC, or left-dominant ARVC) presenting with inflammatory myocardial injury. On follow up the patient remained listed for transplant, and DFTs improved off amiodarone.
Case Media
CXRECGCardiac MRIPET CT (Cardiac Sarcoid Protocol)Click to Enlarge
Episode Schematics & Teaching
Created by Dr.
55. Case Report: Suicide LV post-TAVR – The University of Texas at Austin, Dell Medical School
Sep 11, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join UT-Austin cardiology fellows (Priya Kothapali, Sergio Montano, Travis Benzing, and Michael Grzeskowiak) for a speedboat adventure on Lake Travis! They discuss a fascinating case of Suicide LV post-TAVR. Dr. Mark Pirwitz provides the E-CPR and program director Dr. Clay Cauthen provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her early 70s, with a history of CAD s/p PCI to LAD & RCA with DES six months prior, to presentation, paroxysmal atrial fibrillation s/p ablation, type 2 diabetes mellitus, hypertension, prior TIA, and severe symptomatic AS was admitted for elective TAVR. She underwent successful implantation of a 29mm Medtronic Evolut Pro valve via left common femoral artery access. Post-valve deployment and following protamine administration for heparin reversal, course was complicated by hypotension with PEA arrest requiring CPR for 4 minutes. Intra-op TEE and angiogram showed a well-seated prosthetic valve with trace paravalvular leak and no evidence of acute aortic regurgitation, significant paravalvular leak, pericardial effusion, coronary obstruction, aortic dissection, or access site complications. She was treated for suspected Protamine reaction with high dose steroids & epinephrine. However, she remained hypotensive with MAP in the 50s on high dose Epinephrine, Norepinephrine, and Vasopressin. Hemodynamics by pulmonary artery catheter demonstrated CVP 7, mPA 26, PCWP 18 mmHg and CO/CI 2.8 L/min and 1.3 L/min/m2. Her lactate was elevated at 5.92 mmol/L and EKG demonstrated normal sinus rhythm. Bedside TTE in the ICU showed hyperdynamic LV function with LVEF 70% and near-complete mid to distal cavity obliteration with significant intracavitary gradient. She was diagnosed with post-TAVR suicide LV and managed with aggressive volume resuscitation and rapid wean of Epinephrine/Norepinephrine with improvement in her hemodynamics. She was eventually extubated and discharged on beta-blocker therapy.
Case Media
A. ECGB. CXRClick to Enlarge
A. ECG: Normal sinus rhythm, no evidence of AV block, no ST segment elevation or depression.B. CXR: Pulmonary vascular congestion, no pneumothorax, ETT at level of carina, PAC in appropriate position
Pre-Aortogram
Implantation
Post-Dilation
Post-Aortogram
TEE: Mid-Esophageal Three-Chamber View
TEE: Mid-Esophageal Short Axis View
Abdominal aortography showed no evidence of vascular access si...
54. Case Report: Wild type aTTR Cardiac Amyloid – Washington University in St. Louis
Sep 09, 2020
CardioNerd (Amit Goyal) join Washington University in St. Louis cardiology fellows (Adam Lick, Manny Rivera Maza, and Sam Lindner) for some amazing local St. Louis craft brews! They discuss a fascinating case of wild-type aTTR cardiac amyloid. Prior to meeting up with the group, Amit bumps into Rachita Navara: a Wash U #FIT, aspiring electrophysiologist, & a rock star of the band "The Pacemakers" (be sure to check out their performance at the end of the episode!) who shares thoughts about the program and her cutting edge contributions to the field of EP. Dr. Katie Zhang provides the E-CPR and program director Dr. Andy Kates provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A man in his early 70s, with a history of hypertension, a bicuspid aortic valve, chronic kidney disease and carpal tunnel syndrome presents with two weeks of worsening dyspnea on exertion. At baseline, he is an avid cyclist and noticed he can now only bike ½ mile when before he could bike extended distances. In addition, he noted abdominal swelling and palpitations. Vitals signs showed mild tachycardia, irregularly irregular rhythm, and no clear evidence of volume overload. Labs demonstrated acute on chronic kidney disease, an elevated NT-proBNP and elevated troponin. ECG demonstrated atrial flutter with variable conduction block. TTE demonstrated marked concentric left ventricular hypertrophy with preserved ejection fraction, biatrial enlargement, reduced global longitudinal strain with apical sparing, and bicuspid aortic valve with moderate aortic stenosis. Further diagnostics revealed normal serum kappa/lambda light chains and PYP scan was positive. Patient underwent EMB which demonstrated ATTR amyloid deposition and genetic screening did not show mutations commonly associated with hereditary ATTR.
Case Media
ABCD
A. CXR: Stable mild enlargement of the cardiac silhouette; mildly tortuous aorta. Lung fields are clear, no pneumonia, pleural effusions, or pneumothorax.B. AV continuous wave DopplerC. Strain ImageD. Tc-99 PYP Scan
TTE 1
TTE 4
TTE 2
TTE 5
TTE 3
TC-99 PYP Scan
Strain video 1
Strain video 2
Strain video 3
Episode Schematics & Teaching
Created by Dr. Karan DesaiCreated by Dr. Carine Hamo (updated 9.2020)Click to enlarge!
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Cardiac amyloidosis can have a range of cardiac and extra-cardiac findings as amyloid fibrils can d...
53. Case Report: CTEPH & May Thurner Syndrome – Temple University
Sep 07, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Temple Cardiology Fellows (Anika Vaidy and Anne- Sophie LaCharite-Roberge) in Philadelphia, PA! They discuss a fascinating case of pulmonary hypertension secondary to Chronic Thromboembolic Pulmonary Hypertension (CTEPH) associated with May Thurner syndrome and large uterine fibroids. Dr. Vaidya provides the E-CPR and message to applicants. Episode notes were developed by Johns Hopkins internal medicine resident, Eunice Dugan, with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her late 40s with history of iron deficiency anemia, uterine fibroids, and recurrent DVTs/PEs for the past 6 years despite different anticoagulation regimens, presented with syncope and progressive dyspnea on exertion. Family history was negative for DVT/PE or hypercoagulable states. On exam, she was euvolemic. Labs were significant for anemia, a normal pro-BNP, and a negative extensive hypercoagulable workup. TTE showed interventricular systolic septal flattening, right ventricular outflow tract pulse wave doppler with mid-systolic notch, and shortened acceleration time consistent with elevated pulmonary artery pressure. A VQ scan showed bilateral right greater than left mis-matched perfusion defects. CT angiogram showed right greater than left chronic mural thrombus, correlating with pulmonary angiogram which showed severe proximal and mid-vessel disease on the right and distal disease on the left. RHC corroborated the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) with mean pulmonary artery pressure of 41 and PVR of 5.2 Woods Units (WU).
To determine the etiology of her recurrent clots, a lower extremity venogram was performed and showed 80% stenosis of her left common iliac vein by the overlying right common iliac artery confirming May-Thurner syndrome. Lower extremity venogram also showed severe proximal stenosis of right iliac vein thought to be due to large uterine fibroids. Given her severe proximal and mid-vessel clot burden, she underwent pulmonary thromboendarterectomy with a subsequent drop in pulmonary vascular resistance to 1 WU. The etiology of DVTs and CTEPH was determined to be external compression related to both May-Thurner syndrome and uterine fibroids. To prevent future thromboembolic events, she underwent stenting of her left common iliac vein and hysterectomy. With these interventions, RV function returned to normal, and her symptoms completely resolved!
Case Media
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52. Women’s Heart Health & Women in Cardiology with Dr. Nanette Wenger
Sep 03, 2020
CardioNerds (Amit Goyal & Carine Hamo) discuss the past, present, and future of Women's Heart Health & Women in Cardiology with Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger is a true leader in the field of women’s heart health and a strong proponent for women in cardiology and medicine. Her passion, dedication, and advocacy have inspired countless trainees to carry this torch and continue to build on her truly impactful work. Special introduction by Dr. Martha Gulati and birthday wishes to Dr. Wenger by the entire CardioNerds Team! Special thanks to Dr. Kimberly Manning for her invaluable mentorship.
Episode graphic by Dr. Carine Hamo
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
CardioNerds Episode PageCardioNerds Prevention PageCardioNerds Women's Cardiovascular Health PageCardioNerds Academy - Apply now! Subscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Cardionerds Cardiovascular Prevention Series
References and Links
1. Wenger NK (2005) Women in cardiology: The US experience. Heart.
2. Douglas PS, Rzeszut AK, Noel Bairey Merz C, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L (2018) Career preferences and perceptions of cardiology among us internal medicine trainees factors influencing cardiology career choice. JAMA Cardiol.
3. Wenger NK, Speroff L, Packard B (1993) Cardiovascular Health and Disease in Women. N Engl J Med.
4. Burgess S, Shaw E, Zaman S (2019) Women in Cardiology. Circulation.
Meet Dr. Wenger!
Dr. Nanette Wenger is Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger received her medical degree from Harvard Medical School in 1954 as one of their first female graduates followed by training at Mount Sinai Hospital where she was the first female to be chief resident in the cardiology department. She is among the first physicians to focus on heart disease in women with an expertise in cardiac rehabilitation and geriatric medicine.
Dr. Wenger has received numerous awards including the Distinguished Achievement Award from the Scientific Councils of the American Heart Association and its Women in Cardiology Mentoring Award, the James D. Bruce Memorial Award of the American College of Physicians for distinguished contributions in preventive medicine, the Gold Heart Award, the highest award of the American Heart Association, a Lifetime Achievement Award in 2009 and the Inaugural Bernadine Healy Leadership in Women’s CV Disease Distinguished Award, American College of Cardiology. She chaired the U.S. National Heart, Lung, and Blood Institute Conference on Cardiovascular Health and Disease in Women, is a Past President of the Society of Geriatric Cardiology and is past Chair, Board of Directors of the Society for Women’s Health Research. Dr. Wenger serves on the editorial boards of numerous professional journals and is a sought-after lecturer for issues related to heart disease in women, heart disease in the elderly, cardiac rehabilitation, coronary prevention, and contemporary cardiac care. She is listed in Best Doctors in America.
Carine Hamo,
51. Case Report: Embolic Acute Coronary Syndrome from PFO & Pulmonary Hypertension – Lankenau Medical Center
Aug 28, 2020
CardioNerds (Amit Goyal & Dan Ambinder) join Lankenau Medical Center cardiology fellows (Gwen McNeill and Shaung Ooi) for some Philly cheesesteaks! They discuss a fascinating case of Embolic Acute Coronary Syndrome from PFO and Pulmonary Hypertension. Dr. John Clark provides the E-CPR and program director Dr. Jeanine Romanelli provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A woman in her early 40s with history of tobacco and prior methamphetamine use presented with acute onset chest pain. She was found to have an elevated troponin, anterior T wave inversions, and apical akinesis on TTE. Coronary angiography showed a coronary embolism in the mid-distal LAD. Attempts to wire the lesion led to distal embolization of the clot, and IVUS showed no underlying arteriosclerosis.
To investigate the etiology of the coronary embolus, a repeat TTE with agitated saline was done that suggested a PFO with right to left flow, as well as decreased RV function with an estimated RVSP of 70 mmHg. The clinical picture was that of a paradoxical coronary embolus, arising from the right (venous) side traveling to the left (arterial) side via a PFO. PFO closure was discussed but not performed given severe pulmonary hypertension with Right to Left shunt. In this circumstance, the PFO functions as a "pop-off valve" for the overloaded RV; closing it risks precipitating acute RV overload and failure. A RHC showed a PA pressure of 70/24 mmHg with mPAP of 40 mmHg, PCWP 5 mmHg, and PVR of 11 woods units. Given concern for idiopathic PH, a vasodilator challenge was done which did not show reactivity, and she was started on ambrisentan and sildenafil. Ultimately, the etiology of her pulmonary hypertension was felt to be due to PAH from prior methamphetamine use vs. idiopathic PAH. On follow-up, her PA pressures and RV function had greatly approved, allowing for safe and successful PFO closure in an attempt to prevent future emboli. Final diagnosis: Embolic Acute Coronary Syndrome from PFO & Pulmonary Hypertension.
Case Media
Before treatment: short axisBefore treatment: apical 4Before treatment: RVSPAfter treatment: Short axisAfter treatment: Apical 4After treatment: RVSPClick to enlarge ???
https://youtu.be/XpnJKZuNVrM
1. Coronary angio of embolism2. PFO on TEE with R to L shunt by Doppler3. TTE bubble after PFO closure
Episode Schematics & Teaching
Click to enlarge ???
The CardioNerds 5!
50. Case Report: Hereditary Restrictive Cardiomyopathy – Duke University
Aug 26, 2020
CardioNerds (Amit Goyal & Dan Ambinder) discuss a case of hereditary restrictive cardiomyopathy with Duke University cardiology fellows Navid Nafissi and Sipa Yankey, and Marat Fudim, an advanced heart failure attending. E-CPR is provided by Dr. Richa Agarwal, fellowship program director of advanced heart failure and cardiac transplantation at Duke University with a final message by fellowship director Dr. Anna Lisa Crowley. Episode notes were developed by Johns Hopkins internal medicine resident Colin Blumenthal with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A 69 yo M with history of atrial fibrillation presents with 5 months of progressive HF symptoms, now NYHA class IV. He was found to be grossly volume overloaded, tachycardic in atrial fibrillation, and hypoxic. CXR demonstrated significant cardiomegaly, and labs indicated new normocytic anemia with evidence of hepatic dysfunction and an elevated NT proBNP. TTE demonstrated massive bi-atrial enlargement, preserved ejection fraction, filling pattern consistent with grade III diastolic dysfunction, and torrential TR. The echocardiogram did not have evidence of constrictive pericarditis and agitated saline study showed Right to Left shunt through a likely PFO. MRI to evaluate for infiltrative cardiomyopathy did not show late gadolinium enhancement (LGE). RHC demonstrated findings consistent with restrictive cardiomyopathy including equalization of diastolic pressures, square root sign, and concordance of RV and LV pressures. PYP scan evaluating for TTR amyloid was negative and laboratory workup did not suggest AL amyloid, Fabry's, Hemochromatosis, or storage disease. Patient's symptoms remained refractory and thus eventually underwent successful OHT. Genetic testing eventually revealed missense mutation in MYBPC3 – revealing an inherited cause of restrictive CM for the patient!
Case Media
Chest X-ray-Rate-controlled A fib with frequent PVCs, LPFB, non-specific ST changes
https://youtu.be/LTUaLd2R7js
Episode Schematics & Teaching
Click to enlarge ???
The CardioNerds 5! – 5 major takeaways from the #CNCR case
When thinking about the etiology of a restrictive cardiomyopathy, we can organize the causes into four major categories: Infiltrative (e.g., amyloidosis, sarcoidosis) Storage diseases (e.g., hemochromatosis, Fabry's) Non-infiltrative (e.g., idiopathic, diabetic cardiomyopathy, genetic causes) Endomyocardial (e.g., endomyocardial fibrosis, hypereosinophilic syndrome) On examination, patients with restrictive cardiomyopathy may have prom...
49. Case Report: Platypnea-Orthodeoxia secondary to a PFO – Allegheny Health Network
Aug 24, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) join Allegheny Health Network cardiology fellows (Adnan Khalif, Mahathi Indaram, Kushani Gajjar, and Michael Nestasie) for a lovely Pittsburgh hike and discuss a fascinating case of platypnea-orthodeoxia secondary to a PFO. Dr. Farhan Katchi provides the E-CPR and Program director Dr. Craig Alpert provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A 64 y/o female with a history of venous and arterial embolism on anticoagulation, known PFO, and obesity presented after a fall. There was no loss consciousness, pre-syncopal symptoms, chest pain, aura, weakness, or palpitations. She had no recent preceding illness. When she arrived in the ED she was hypoxic to 87% on ambulation on room air and required 4L of nasal cannula O2 supplementation. The AGH CardioNerds were consulted!
On examination, the team noted that upon sitting up the patient would desaturate to the mid 80% but when lying down oxygen saturation would improve to 95%! Her ECG demonstrated a RBBB and no acute ST-T changes. TTE was obtained and showed normal LV and RV function and size, no valvular disease, and a likely PFO on an agitated saline study. Cardiac MRI revealed mild RV hypertrophy and Qp:Qs of 0.8 (right/pulm cardiac output < left/systemic cardiac output, indicating right to left shunting). RHC showed normal right-sided pressures. A right femoral vein bubble study was done showing torrential right to left shunting! She underwent PFO closure and her platypnea-orthodexia resolved; she was discharged on room air.
Case Media
Episode Schematics & Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Platypnea-orthodeoxia syndrome (POS) is when dyspnea (Platypnea) and hypoxia (Orthodeoxia) are present in the upright position, but improve upon lying flat. One cause is ARLIAS, or Acute Right-to-Left Inter-Atrial Shunting, which requires an anatomic component (I.e., ASD or PFO) and a functional component (I.e., PH, PE, RV failure) for Right-to-Left shunting to occur A PFO, or patent foramen ovale is a common congenital defect and typically will not lead to hypoxia unless there is right to left shunting. Typically flow is left to right due to an LA to RA pressure gradient and lower compliance of the RV. Remember when evaluating for a PFO with agitated saline, the timing of the appearance of bubbles is important! Early appearance of bubbles (seen in less than...
48. Case Report: Critical Bicuspid Aortic Valve Stenosis Complicating Pregnancy – Vanderbilt University
Aug 21, 2020
CardioNerds (Amit & Dan) join Vanderbilt University cardiology fellows (Tara Holder, Majd El-Harasis, and Amar Parikh) for a Sunday morning brunch, Nashville style! They discuss an enthralling case of bicuspid aortic valve with critical aortic stenosis complicating pregnancy. Program director Dr. Julie Damp provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A 22yo transgender F2M man (G1P0000) at 32w5d was found to have a late-peaking systolic ejection murmur on a regularly scheduled OB visit. He reported recent left-sided exertional chest pain and intermittent lightheadedness, as well as a history of a childhood heart murmur. TTE showed a bicuspid aortic valve (LCC-NCC fusion) with severe aortic stenosis (peak velocity 4.83 m/s, mean gradient of 56 mmHg, AVA at 0.5 cm2 and Dimensionless Index at 0.15). Furthermore, there was preserved ejection fraction and no associated aortopathy.
Following a syncopal episode, the patient was admitted for cardiac optimization prior to delivery. With shared decision making, he ultimately delivered via cesarean section prior to valvular intervention. Post-partum, he underwent balloon aortic valvuloplasty with improvement in mean aortic gradient to 27 mmHg and trace aortic insufficiency. He was asymptomatic at 5 months post-procedure with similar gradients across the aortic valve on TTE.
Case Media
Chest - X ray Final gradients: Peak velocity 4.83 m/s Mean >50 (56) mmHg AVA 0.5 (AVAi=0.27) DOI=0.15
https://youtu.be/YF8TrNmsGh4
Episode Schematics & Teaching
Click to enlarge ???
The CardioNerds 5! – 5 major takeaways from the #CNCR case
Hemodynamics change dramatically during pregnancy. Cardiac output increases by 30-50% during pregnancy due to: ↑ SV, ↑HR, ↓SVR. Immediately post-partum, patients with existing valvular lesions are at high risk of heart failure! Hemodynamic changes peripartum are unpredictable. ↑Preload: relief of IVC compression, auto-transfusion of 300-500mL blood from placenta with each uterine contraction, and intravenous fluids and/or blood products. ↓Preload: hemorrhage ↑Afterload: SBP & DBP increase with each uterine contraction ↓Afterload: systemic vasodilation from epidural and spinal analgesia ↑CO: by up to 30% in the first stage of labor and up to 80% in the immediate post-partum period. 2/2 ↑SV. Most pregnant patients with symptomatic AS can be managed medically,
47. Case Report: Syphilitic Aortitis with Severe Aortic Regurgitation – UT Southwestern
Aug 19, 2020
CardioNerds (Amit & Dan) join UT Southwestern cardiology fellows (Shreya Rao, Sonia Shah, and Nick Hendren) for some delicious Dallas Tacos! They discuss a fascinating case of syphilitic aortitis with severe aortic regurgitation presenting as cardiogenic shock. Program director Dr. Gail Peterson provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case figures & media - Case teaching - Educational video - References - Production team
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Patient Summary
A 57 year old male presents with 3 months of progressive dyspnea on exertion, orthopnea and lower extremity edema. However, his symptoms suddenly worsened over the past few days. He has no other known medical history or prior surgeries. Further, he denies tobacco, alcohol or illicit drug use and reports a preference for male sexual partners. On presentation to the hospital, he had a markedly wide pulse pressure, a decrescendo diastolic murmur at the left upper sternal border and a water hammer pulse readily identifiable. TTE confirmed the clinical findings of severe aortic regurgitation with holodiastolic flow reversal in the thoracic, as well as the thoraco-abdominal aorta. Right heart catheterization was performed and showed equalization of the LVEDP and aortic diastolic pressure at 40 mmHg with Cardiac Output of 1.73 L/min. RPR was positive at a high titer (1:512). He was ultimately diagnosed with syphilitic aortitis with severe aortic regurgitation. He progressed to cardiogenic shock and was managed with nitroprusside, dobutamine, and furosemide infusion as well as IV penicillin for syphilitic aortitis and presumed neurosyphilis. The patient was stabilized and eventually underwent an uncomplicated prosthetic aortic valve replacement and aortic root resection and reconstruction and has done well post-operatively! Pathology was consistent with syphilitic aortitis: "lymphoplasmacytic inflammation, large foci of necrosis, and neovascularization"
Case Media
CXR: Cardiomegaly, bilateral pleural effusions, evidence of pulmonary congestionNormal sinus rhythm, left atrial enlargement, LVH and possible septal infarct.LV tracing (black), Aortic tracing (red)Apical long view with color Doppler noting marked flow through aortic valve during diastole.Continuous Doppler through trileaflet aortic valve consistent with severe AI (P1/2 92 msec).Pulse wave Doppler of abdominal aorta demonstrating holodiastolic flow reversal consistent with severe AI.Click to enlarge ???
Episode Schematics & Teaching
The CardioNerds FiveSevere Aortic RegurgitationPathophysiology of Aort...
46. Introducing CardioNerds Case Reports: Recruitment Edition Series – with Dr. Nosheen Reza
Aug 17, 2020
CardioNerds Amit and Dan are joined by Dr. Nosheen Reza, chair of the ACC FIT section, to announce the launch of the CardioNerds Case Reports: Recruitment Edition Series! In this exciting project, the CardioNerds collaborated with the ACC FIT section to invite every fellowship program to co-produce a case-based episode. Fellows from the program present and discuss a fascinating case and an expert provides the E-CPR editorial, followed by a message to applicants from the program director. We've asked every program to help us promote diversity in their fellow ambassadors to the CardioNerds show.
We also discuss the value of podcasts and innovations in medical education, Dr. Reza's perspectives and advice for the upcoming virtual recruitment, getting involved with the ACC as fellows-in-training (#FIT!), promoting diversity and inclusion within cardiology, and Dr. Reza's advice for thriving during fellowship.
We also introduce the brand new CardioNerds Academy! We will be growing the platform by offering a uniquely tailored and mentored experience to several future CardioNerds Fellows. Our goal is to teach our CardioNerds Fellows the ropes of med-ed podcasting through a comprehensive curriculum with dedicated mentorship. We are honored to have recruited Dr. Justin Berk as program director and Dr. Heather Kagan as associate program director.
Episode graphic by Dr. Carine Hamo
CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza
Key Reference: Reza N, Krishnan S, Adusumalli S. A Model for the Career Advancement of Women Fellows and Cardiologists. J Am Coll Cardiol. 2020;76(8):996 LP - 1000.
Nosheen Reza, MD
Dr. Nosheen Reza is a cardiologist and translational researcher at the University of Pennsylvania focusing on advanced heart failure and transplant cardiology and cardiovascular genetics, genomics, and phenomics. She obtained her medical degree from the University of Virginia School of Medicine in 2012 and completed her internal medicine residency training at the Massachusetts General Hospital in 2015. She then completed her Cardiovascular Disease fellowship at the University of Pennsylvania in 2018 and served as 2017-2018 Chief Fellow. At Penn, Dr. Reza pursued additional scholarship in genomic medicine as an NIH T32-funded postdoctoral fellow and in healthcare quality as a Penn Benjamin & Mary Siddons Measey Fellow in Quality Improvement and Patient Safety. She completed her final year of clinical training at Penn in Advanced Heart Failure and Transplant Cardiology and joined the faculty at the University of Pennsylvania in July 2020. Dr. Reza is passionate about medical education and has won many distinctions in the field throughout her training. She serves as an editorial board member for JACC: Case Reports, JACC: CardioOncology, and Current Cardiovascular Risk Reports. Dr. Reza is an active leader in the Heart Failure Society of America, American Heart Association, and American College of Cardiology at the local and national levels and volunteers on multiple leadership councils and steering committees within these organizations.
CardioNerds Case Reports: Recruitment Edition Series Production Team
Daniel Ambinder, MDAmit Goyal, MDHeather Kagan, MDJustin Berk, MD MPH MBA
45. Case Report: COVID Myocarditis – Cleveland Clinic
Aug 14, 2020
CardioNerds (Amit Goyal & Daniel Ambinder) discuss a case report of COVID myocarditis and cardiogenic shock with Dr. Travis Howard and Dr. Zach Il'Giovine, cardiology fellows at the Cleveland Clinic. Dr. Nir Uriel, Professor of Medicine at Columbia University and Director of Advanced Heart Failure and Transplant at NewYork-Presbyterian Hospital Network in New York joins to discuss COVID-19 myocarditis and management of cardiogenic shock.
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
Check out the Cardionerds Cardiology Case Reports Topic Page Check out the Cardionerds Topics and Episode page for all podcast episodesSupport our educational mission by becoming a Patron!
Case Summary
Healthy and physically fit incarcerated 49M who presents with 2 weeks of fevers, myalgias, and SOB. His past medical history includes GSW to abdomen, psoriasis not currently on medications, prior tobacco and alcohol abuse. Transferred for undifferentiated shock on norepinephrine, and was found to be in sinus tachycardia to 110 bpm, hypotensive despite vasopressor infusions with labs showing a hyperinflammatory state, multi-organ failure, and eventually found to be COVID+. The patient quickly progressed into refractory cardiogenic shock requiring VA-EMCO, as well as Impella placement for LV unloading. The patient underwent endomyocardial biopsy with electron microscopy which was notable for COVID virions in the myocardium and was diagnosed with COVID myocarditis. Interestingly, his chest CT showed normal lung parenchyma and therefore presented as isolated cardiac involvement of COVID-19. The patient improved with tocilizumab, IVIG, and steroids.
Episode Producer: Colin Blumenthal, MDMedical Education Mentor: Karan Desai, MD
Episode graphic by Dr. Carine Hamo
The CardioNerds 5! - 5 major takeaways from the #CNCR case
Diagnose Cardiogenic Shock at the Bedside! Exam: Narrow Pulse Pressure, Labored Breathing, Cheyne-Stokes Respirations, Abdominal Bloating/Nausea, Cool Extremities, Oliguria, Altered Mental Status If PAC available, low central (PA) mixed venous saturation (<55-60%) suggestive* of cardiogenic shock COVID-19 can cause myocardial injury through several mechanisms Ischemic - Supply/Demand Mismatch, Acute Plaque Rupture Nonischemic - Stress Cardiomyopathy, Lymphocytic Infiltration, Direct Viral Cardiomyocyte Injury, Bystander Injury from Systemic Inflammation Different forms of mechanical support give varying levels of cardiac output and pulmonary support Consider VA-ECMO in refractory cardiogenic shock, especially if there is evidence of biventricular failure +/- pulmonary compromise VA-ECMO may require "LV unloading" when there is high afterload leading to pulmonary congestion and/or stasis of blood flow in the LV
Myocarditis Infographic
https://twitter.com/CBlumenthal2/status/1295043817855475715?s=20
References
Dexamethasone in Hospitalized Patients with COVID-19 Non-invasive imaging in the diagnosis of acute viral myocarditis Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness: The ESCAPE Trial Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation Remdesivir for the Treatment of Covid-19 - Preliminary Report Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial
...
44. Coronary Artery Calcium Scoring with Dr. Michael Blaha
Aug 10, 2020
The CardioNerds discuss Coronary Artery Calcium Scoring with Dr. Michael Blaha, Director of Clinical Research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Joining the discussion is Dr. Gabriel Shaya, cardiology fellow at the Johns Hopkins Hospital and prevention researcher. Carine Hamo, Heather Kagan and Dan Ambinder take a deep dive into the crunchy and calcified world of coronary artery disease discussing the evidence and utility of coronary artery calcium scoring as a powerful tool for individualized risk stratification of cardiovascular disease prevention.
Cardionerds Cardiovascular Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
The Cardionerds CV prevention series includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Cardionerds Cardiovascular Prevention Series
References and Links
https://www.mesa-nhlbi.org/CAC-Tools.aspxBlaha MJ, Blankstein R, Nasir K. Coronary Artery Calcium Scores of Zero and Establishing the Concept of Negative Risk Factors. J Am Coll Cardiol. 2019;74(1):12-14. Peng AW, Mirbolouk M, Orimoloye OA, et al. Long-Term All-Cause and Cause-Specific Mortality in Asymptomatic Patients With CAC ≥1,000: Results From the CAC Consortium. JACC Cardiovasc Imaging. 2020;13(1 Pt 1):83-93. Shaya GE, Al-Mallah MH, Hung RK, et al. High Exercise Capacity Attenuates the Risk of Early Mortality After a First Myocardial Infarction: The Henry Ford Exercise Testing (FIT) Project. Mayo Clin Proc. 2016;91(2):129-139.
Dr. Michael Blaha is an Associate Professor of Cardiology and Epidemiology and presently serves as the Director of Clinical Research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Dr. Blaha completed both his MD and MPH and Vanderbilt University. He then completed his Internal Medicine residency in the Osler Medical Housestaff Training Program at Johns Hopkins where he also completed fellowship training. He is an Associate Editor for the Journal of Cardiovascular Computed Tomography, Associate Editor for the Diabetes and Cardiometabolic Clinical Community on acc.org and is a standing member of the Endocrinologic and Metabolic Drug Advisory Committee (EMDAC) for the FDA. He is Principal Investigator for the Coronary Artery Calcium Consortium, co-chair of the Cross-Cohort Collaboration, and a Principle Investigator for the American Heart Association (AHA) Tobacco Regulation and Addiction Center.
Dr. Gabriel Shaya earned both his Medical Degree and Masters of Public Health at the University of Miami Miller School of Medicine. He went on to complete his residency in Internal Medicine at the New York Presbyterian – Weill Cornell Medical Center. He has returned to his hometown of Baltimore for Cardiology fellowship with the intent of pursuing a career as an academic cardiologist. His clinical and research interests center on the refinement of cardiovascular risk assessment with the goal of tailoring preventive therapies to avert adverse cardiovascular events before they happen.
Michael Joseph Blaha, M.D., M.P.H.Gabe Shaya, MD,
43. Introducing CardioNerds Case Reports – with Dr. Julia Grapsa
Aug 06, 2020
JACC: Case Reports Editor-in-Chief, Dr. Julia Grapsa joins Cardionerds, Amit and Dan, to introduce a new episode series: CardioNerds Case Reports (#CNCR)! We discuss the value of learning through cases, podcasts and other innovations in education, importance of promoting wellness in medicine, the editorial review process for case reports, and being an editor-in-chief as a woman in medicine.
The CardioNerds Case Reports series will shine light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an "Expert CardioNerd Perspectives & Review" (E-CPR) for a nuanced teaching from a content expert.
We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
Take me to the Cardionerds Case Report (CNCR) Series PageTake me to the Cardionerds Episode Topics Page
Episode graphic created by Dr. Carine Hamo
References
Grapsa J (2019) Voices in Cardiology. JACC Case Reports.
Grapsa J, Fuster V (2019) JACC: Case Reports: New Era of Clinical Cases, Bridging Patients With Guidelines. J Am Coll Cardiol.
Grapsa J, Fuster V (2020) JACC: Case Reports: Moving to a Multimedia Educational Vehicle. J Am Coll Cardiol.
(2006) Mindset: the new psychology of success. Choice Rev Online.
Balasubramanian S, Saberi S, Yu S, Duvernoy CS, Day SM, Agarwal PP (2020) Women representation among cardiology journal editorial boards. Circulation.
Dr. Julia Grapsa serves as the Editor-in-Chief of JACC: Case Reports. Dr. Grapsa worked for Cleveland Clinic Abu Dhabi and then she moved to UK as a a consultant cardiologist for Barts Heart Center. In March 2020, Dr. Grapsa started working as consultant cardiologist at Guys and St Thomas NHS Trust. Within the UK’s leading structural valve disease group, Dr. Grapsa is responsible for the valvular heart disease network and echocardiography, a position previously held by Professor John Chambers. Dr. Grapsa has served as chair of the young community for multimodality imaging for the European Association of Cardiovascular Imaging and as a member of the European Society of Cardiology (ESC) education committee, leading the ESC clinical case gallery. She was responsible for ESC social media, since its birth and she has been a member of imaging and online education committees of Heart Failure Association. Prior to her role as JACC: Case Reports editor-in-chief, Dr. Grapsa served as an editorial consultant for JACC: Cardiovascular Imaging. She is a fellow of the ACC, the American Heart Association, the American Society of Echocardiography and the European Society of Cardiology.
Julia Grapsa, MD, PhD, FACC
Amit Goyal, MD
Daniel Ambinder, MD
42. Lipid Management with Drs. Ann Marie Navar & Nishant Shah
Aug 02, 2020
The CardioNerds discuss Lipid Management with Dr. Ann Marie Navar and Dr. Nishant Shah from Duke Medical Center, Division of Cardiology. Amit, Carine and Dan take a deep dive into the greasy world of lipids and cholesterol, covering lipid metabolism, therapeutic targets, approach across the entire spectrum of predicted risk, and key common management scenarios (statin intolerance, hypertriglyceridemia, elevated LP(a)), and more.
Episode 42. Lipids and Cholesterol with Drs. Drs. Ann Marie Navar and Nishant Shah
Take me to the Cardionerds Cardiovascular Prevention PageTake me to episode topics page
The Cardionerds CV prevention series will include in-depth deep dives on so many topics related to prevention starting with this case discussion. Stay tuned for upcoming episodes on the ABCs of prevention, obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more!
Key references:
Toth, P. P. (2020). Familial Hypercholesterolemia and Lipoprotein(a): Unraveling the Knot That Binds Them. Journal of the American College of Cardiology, 75(21), 2694–2697.Michos, E. D., McEvoy, J. W., & Blumenthal, R. S. (2019). Lipid management for the prevention of atherosclerotic cardiovascular disease. New England Journal of Medicine, 381(16), 1557–1567. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 73(24), e285–e350.Lloyd-Jones, D. M., Braun, L. T., Ndumele, C. E., Smith, S. C., Sperling, L. S., Virani, S. S., & Blumenthal, R. S. (2019). Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report from the American Heart Association and American College of Cardiology. Circulation, 139(25), E1162–E1177.Laufs, U., Parhofer, K. G., Ginsberg, H. N., & Hegele, R. A. (2020). Clinical review on triglycerides. European Heart Journal, 41(1), 99–109.ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 74(10), 1376–1414.
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Cardionerds Cardiovascular Prevention Series
Dr. Ann Marie Navar is a cardiologist and epidemiologist at the Duke Clinical Research Institute focusing on cardiovascular disease prevention. She received an MD from Duke University and a PhD in Global Disease Epidemiology and Control from the Johns Hopkins School of Public Health in 2009 before completing residency in internal medicine and pediatrics and fellowship in cardiology at Duke. Dr. Navar’s research focuses on improving cardiovascular disease prevention through better identification of at-risk populations, targeted interventions to improve quality of care and patient engagement through the electronic health record, and better treatment of hypertension and cholesterol to lower CV risk. She also studies the impact of payer-imposed barriers to novel therapies. Her areas of expertise include risk prediction, patient risk communication, real world data analyses using EHR- and claims-based datasets, and registries. She is an associate editor at JAMA-Cardiology and a board membe...
41. Women’s Cardiovascular Prevention with Dr. Leslie Cho
Jul 26, 2020
The CardioNerds discuss Women's Cardiovascular Prevention with Dr. Leslie Cho, Interventional Cardiologist and Director of the Cleveland Clinic’s Women’s Cardiovascular Center. She is also Section Head of Preventive Cardiology and Rehabilitation in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic. Amit, Dan and Carine take a deep dive into women's cardiovascular prevention and discuss the epidemiology, unique risk factors, different manifestations of CVD and treatment strategies to lower cardiovascular risk in women. Tune in as we discuss cases from the CardioNerds Women's Clinic to learn more!
Take me to the Cardionerds Cardiovascular Prevention PageTake me to episode topics page
Cardiac Consult PodcastTall Rounds Lectures
Key Reference: Cho L, Davis M, Elgendy I, et al (2020) Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review. J Am Coll Cardiol 75:2602–2618
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Cardionerds Cardiovascular Prevention Series
Dr. Leslie Cho is a professor of Medicine at Cleveland Clinic Lerner School of Medicine Case Western Reserve Medical School and serves as Director of the Cleveland Clinic’s Women’s Cardiovascular Center. She is also Section Head, Preventive Cardiology and Rehabilitation in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic. Dr. Cho received her undergraduate degree in interdisciplinary studies from the University of California, Los Angeles, graduating cum laude. She received her medical degree from the University of Chicago Pritzker School of Medicine, and took her residency in internal medicine at the University of Washington Medical Center where she received the John Humphrey Award as Most Outstanding Internal Medicine Resident. Her clinical training continued when she accepted a fellowship in cardiology, followed by a fellowship in interventional cardiology and peripheral disease, both from Cleveland Clinic.
Leslie Cho, MDAmit Goyal, MDCarine Hamo, MDDaniel Ambinder, MD
40. The ‘ABC’s of Cardiovascular Prevention with Dr. Roger Blumenthal
Jul 19, 2020
The CardioNerds discuss The 'ABC's of Cardiovascular Prevention with Dr. Roger Blumenthal, Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and co-chairperson of the 2019 American College of Cardiology/American Heart Guideline on prevention of cardiovascular disease. Joining the discussion is Dr. David Feldman, Osler housestaff and first author of a beautiful State-of-the-Art review in the American Journal of Preventive Cardiology discussing a comprehensive ABCs of prevention.
A: Assess Risk, Anti-Inflammatory, AspirinB: Body weight, Blood PressureC: Cigarette Cessation, CholesterolD: Dream (sleep), Diet, Digital Health, DiabetesE: Exercise F: Factors of the EnvironmentG: Genetics
Take me to the Cardionerds Cardiovascular Prevention PageTake me to episode topics page
Key Reference: Summarizing 2019 in Cardiovascular Prevention using the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease’s ‘ABC’s Approach
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Dr. Roger Blumenthal is a Professor of Medicine and the Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease for which he was the principal developer. He received his medical degree from Cornell Medical College, where he was awarded the Weiss Prize for Excellence in Clinical Medicine. He completed his internal medicine and cardiology fellowship training at The Johns Hopkins Hospital before joining the Johns Hopkins cardiology faculty. Dr. Blumenthal was the most recent recipient of the Landon School Anthony Kupka Distinguished Alumnus Award. He was co-chairperson of the 2019 American College of Cardiology/American Heart Guideline on prevention of cardiovascular disease.
Dr. David Feldman is a Junior Assistant Resident in the Osler Medical Residency Program at the Johns Hopkins Hospital. Prior to joining the housestaff, David received his MD and MPH degrees from the University of Miami. David first joined the Ciccarone Center as a pre-doctoral fellow in 2013 under the mentorship of Drs. Roger Blumenthal and Mike Blaha. David is passionate about cardiovascular disease prevention and hopes to pursue a career in academic cardiology, with a particular interest in preventive cardiology.
Roger Scott Blumenthal, M.D.David Feldman, MDCardionerds Cardiovascular Prevention SeriesDaniel Ambinder, MDAmit Goyal, MDCarine Hamo, MD
CardioNerds Amit Goyal and returning guest Dr. Zach Il’Giovine explore the patient's perspective on cardiovascular prevention with the star patient of this series: Kanak Amin. to explore the patient perspective on cardiovascular prevention. Mr. Amin tells us about his perspectives on being a heart patient and offers important advice for both patients and providers on the. He gives us many pearls, but especially highlights the importance of diabetes education, cardiac rehabilitation, engaging loved ones, and getting to know the patient on a deeper level.
Special messages from Dr. Wael Jaber and Dr. Nishant Shah, who both knew Mr. Amin as a colleague, friend, and patient.
Take me to the Cardionerds Cardiovascular Prevention PageTake me to episode topics page
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
Kanak Amin is the Program Manager of the Radiochemistry Nuclear Medicine program at Cleveland Clinic. His hobbies and interests include woodworking, learning Wall Street and the financial world as well as computer web design. We are so appreciative this phenomenal patient perspective on cardiovascular prevention!
Dr. Zachary Il’Giovine is a general cardiology fellow at the Cleveland Clinic. He received his medical degree from the Wright State University Boonshoft School of Medicine before completing internal medicine training at Duke University. He has clinical interests in advanced heart failure and cardiac critical care. Outside of the hospital he loves playing soccer and spending time with his wife Clare and son Luca.
Kanak AminNishant Shah, MDZachary Il’Giovine, MD
Amit Goyal, MDCardionerds Cardiovascular Prevention Series
38. Cardiovascular Prevention: A Case Discussion by the Cardionerds
Jul 12, 2020
This is the first episode in an important series on cardiovascular prevention. It's no secret that cardiovascular disease is the #1 killer worldwide; the total impact on humanity is just staggering. A focus on preventing CVD is an impetus for every cardionerd. In this episode Dan, Amit, Carine, and Heather discuss an illustrative case discussion and review the Cardionerds 2+4 paradigm of cardiovascular prevention: 2 fundamental principles of management + 4 steps in risk stratification.
The Cardionerds CV prevention series will include in-depth deep dives on so many topics related to prevention starting with this case discussion. Stay tuned for upcoming episodes on the ABCs of prevention, obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women's cardiovascular prevention, coronary calcium scoring and so much more!
Take me to the Cardionerds Cardiovascular Prevention PageTake me to episode topics page
We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association.
TWO principles of management
Emphasize healthy lifestyle for everyone regardless of riskEscalate Preventive Measures with ↑ Risk
FOUR steps of risk stratification
Qualitative risk approximation - identify major risk factors and start counseling and education. Quantitative risk estimation - use a validated model to quantify a patient’s future risk of CVD. Identify Risk Enhancing Factors - personalize risk if patient is in the gray zones after step 2Measure coronary artery calcium score - selectively if risk remains uncertain
Cardiovascular Prevention
Amit Goyal, MDDaniel Ambinder, MDCarine Hamo, MDHeather Kagan, MD
37. Palliative Care in Heart Failure with Dr. Rab Razzak
Jun 21, 2020
The role of palliative care in the management of heart failure is discussed by palliative care expert, Dr. Rab Razzak, clinical associate professor and clinical director of palliative care at University Hospital Cleveland Medical Center. CardioNerds host Amit Goyal is joined by special guest interviewer, Dr. Arsalan Derakhshan, Assistant Program director at Case Western Internal Medicine residency program and the head of the Global Health Pathway as well as co-host of the Clinical Problem Solvers podcast!
Take me to the Heart Failure Topic PageTake me to episode topics page
Dr. Rab Razzak went to medical school at Bangledesh Medical College and internal medicine residency at St. Joseph Regional Medical Center in Patterson, NJ. He worked initially as a hospitalist at Cedars Sinai and was grandfathered into palliative care. He moved to Maryland to work at Johns Hopkins, where he practiced for 4.5 years. He is now a clinical associate professor and clinical director of palliative care at University Hospital Cleveland Medical Center. He is also a devoted husband, dedicated father, and a stand-up comedian! We could think of no one better to discuss Palliative Care in Heart Failure than Dr. Razzak.
Dr. Arsalan Derakhshan was born in Iran and moved to Atlanta, Georgia as a young child. He loves to travel and considers himself a global citizen. After graduating from Emory University, he attended the Medical College of Georgia and completed internal medicine residency at Johns Hopkins Hospital. He spends his time attending on inpatient team, staffing resident clinic, and working as the global health track director. He enjoys working with medical students and interns to help them discover their passions. His primary interests include clinical reasoning, global health, and medical innovations. He co-hosts one of the most popular medicine podcast, The Clinical Problem Solvers and has been incredibly instrumental in the launch of The CardioNerds!
Rab Razzak, MDArsalan Derakhshan, MDCardioNerds Heart Failure Series
36. Diuretics, ARNi, SGLT2/GLP1 therapies and iron for HFpEF with Dr. Robert Mentz
Jun 14, 2020
Dr. Robert Mentz, director of the Heart Failure section in the Duke Division of Cardiology, discusses diuretics, anti-hyperglycemic therapies including SGLT2/GLP1 agents, angiotensin receptor-neprilysin inhibitors (ARNi), iron as therapies for Heart Failure with Preserved Ejection Fraction (HFpEF). Additionally, study design and ongoing research in HFpEF is discussed. At the end of the episode Dr. Mentz provides an additional update that highlights how the COVID-19 pandemic has influenced clinical trials around the world. Special thanks to guest interviewers, Duke cardiology fellows, Dr. Kelly Arps and Dr. Rahul Loungani!
On the CardioNerds Heart Failure topic page you’ll podcast episodes, references, guest experts and contributors, and so much more.
Take me to the Heart Failure Topic PageTake me to episode topics pageAcute Decompensated Heart Failure Primer – Youtube
Dr. Robert Mentz completed internal medicine training at Brigham and Women’s Hospital and cardiology fellowship followed by advanced heart failure and transplant cardiology training at Duke University Hospital and the Duke Clinical Research Institute. He is the new director of the Heart Failure section in the Duke Division of Cardiology. His areas of clinical and research focus include treating comorbid diseases in heart failure patients, use of biomarkers and surrogate and non-fatal outcomes in heart failure trials, and novel therapeutic approaches to heart failure. Dr. Mentz is heavily involved in many clinical trials and serves as the associate editor at Circulation: Heart Failure. In addition to his clinical and research endeavors, Dr. Mentz is heavily invested in the cardiology fellowship where he serves as associated program director and renown mentor for which he has won many fellow-nominated awards. Finally, as former director of the Duke University Cooperative Cardiovascular Society, he expanded the network of current and former Duke trainees to be a leading enroller in clinical trials. We are really excited about him joining the show to discuss Diuretics ARNi SGLT2/GLP1 therapies for HFpEF.
Dr. Rahul Loungani completed medical school at the medical university of SC and then traveled to Baltimore for internal medicine training in the Osler Residency Program at the Johns Hopkins Hospital. Here he fell in love with the management and hemodynamics of critically ill patients. He is currently a third-year cardiology fellow at Duke University Medical Center where he will also be pursuing fellowship in advanced heart failure and transplant cardiology next year. His current interests are in Cardiac amyloid, in particular it's arrhythmic manifestations, early diagnosis, and novel therapeutics. He also loves teaching the housestaff and was awarded the Cassell-Saperstein award at Duke, recognizing the fellow who most demonstrates a commitment to teaching and passion for clinical education. Outside of the hospital loves being a new dad to baby Arya.
Dr. Kelly Arps completed medical school at Emory University school of medicine and internal medicine training in the Osler Residency Program at the Johns Hopkins Hospital. She is currently is pursuing her cardiology fellowship at Duke University Medical Center.
CardioNerds Heart Failure Series
35. Heart Failure with Preserved Ejection Fraction with Dr. Kavita Sharma
Jun 08, 2020
We discuss Heart Failure with Preserved Ejection Fraction (HFpEF) with Dr. Kavita Sharma, director of the Heart Failure with Preserved Ejection Fraction Program and interim director of Advanced Heart Failure Transplant section at The Johns Hopkins Hospital. CardioNerds hosts Carine Hamo and Daniel Ambinder are joined by Dr. Beth Feldman (resident at The Johns Hopkins Hospital). Topics discussed include a definitions, diagnosis, phenotypic presentations, inpatient management of acute decompensated heart failure, role of dopamine, advanced therapies of HFpEF, and the Paraglide trial.References mentioned in this episode can be found here
On the CardioNerds Heart Failure topic page you’ll podcast episodes, references, guest experts and contributors, and so much more.
Take me to the Heart Failure Topic PageTake me to episode topics pageAcute Decompensated Heart Failure Primer – Youtube
Dr. Kavita Sharma graduated from the University of Virginia School of Medicine and completed her residency and served as the assistant chief of service, cardiology fellowship and advanced heart failure fellowship at the Johns Hopkins Hospital. She is the Director of the Johns Hopkins Heart Failure with Preserved Ejection Fraction Program and is currently the interim director of Advanced Heart Failure Transplant section at Hopkins. She has a specialized interest in heart failure with preserved ejection fraction (HFpEF), and directs one of the largest programs in the country dedicated to caring for patients with this condition. She is the principal investigator of numerous clinical and translational trials in HFpEF and leads a team of nurses, research coordinators, and fellows-in-training in this multifaceted program. She is an invited speaker at national meetings in topic areas covering advanced heart failure and HFpEF.
Dr. Beth Feldman graduated from Temple University School of Medicine and is currently on the Longcope Firm on the Osler Medical Service at Johns Hopkins University Hospital. Before pursuing a career in medicine, she worked in health care consulting focusing in health systems. She is passionate about health policy and health systems research. She is hoping to pursue a career in cardiology, with a particular interest in critical care.
Kavita Sharma, MDBeth Feldman, MDCardioNerds Heart Failure Series
34. Interventional Cardiology in Heart Failure with Dr. Jeffrey Moses
May 31, 2020
Interventional cardiology and structural interventions in heart failure are discussed by Dr. Jeffrey Moses, Director of Interventional Therapeutics at Columbia University Medical Center Director of Advanced Cardiac Interventions at St Francis Hospital and Heart Center in Roslyn, NY. CardioNerds hosts Amit Goyal and Daniel Ambinder are joined by Dr. Jackie Latina (Cardiology fellow at The Johns Hopkins Hospital). Topics discussed include percutaneous intervention and complex and high-risk coronary intervention (CHIP), treatment of functional mitral and tricuspid regurgitation, aortic stenosis, and the utility of interatrial shunt devices for the treatment congestive heart failure.
On the CardioNerds Heart Failure topic page you’ll podcast episodes, references, guest experts and contributors, and so much more.
Take me to the Heart Failure Topic PageTake me to episode topics pageAcute Decompensated Heart Failure Primer – Youtube
Dr. Jeffrey W. Moses completed medical school at the University of Pennsylvania School of Medicine and his internship, residency and fellowship in Cardiology at the Presbyterian University of Pennsylvania Medical Center. He currently serves as Director of Interventional Cardiovascular Therapeutics at Columbia University Medical Center and as Director of Advanced Cardiac Interventions at St Francis Hospital and Heart Center in Roslyn, NY. Dr. Moses is an Associate Director of the Transcatheter Cardiovascular Therapeutics (TCT) conference. He has served as lead investigator for numerous national and international clinical studies and he has made important contributions in the areas of clinical research and educational activities in interventional vascular therapy. He is also a pioneer in developing approaches involving minimally invasive surgery, angioplasty, gene therapy, novel imaging technologies and various support devices that allow for wider application of interventional cardiovascular procedures.
Dr. Jacqueline Latina was born and raised in the suburbs of Boston, MA, but fortunately escaped without a Boston accent. She is a graduate of Princeton University with an A.B. in chemistry. She earned her M.D. at Tufts University School of Medicine. Her internship and internal medicine residency were completed at Mount Sinai Hospital in New York City, where she stayed on for an American Heart Association postdoctoral research fellowship. She completed an M.S. in clinical research methods at the Columbia Mailman School of Public Health during that time. She is currently a cardiology fellow at Johns Hopkins Hospital, and plans to start interventional cardiology fellowship in June 2020. She chuckles if you ask “Are you Latina?”
Jeffrey W. Moses, MDJacqueline Latina, MDCardioNerds Heart Failure Series
33. Cardiac MRI with Dr. Deborah Kwon
May 26, 2020
The Cleveland Clinic Director of Cardiac MRI, Dr. Deborah Kwon, discusses the principles and clinical applications of cardiac MRI, taking us from the protons to the bedside with a series of illustrative cases. CardioNerds hosts Amit Goyal, Daniel Ambinder, and Carine Hamo are joined by Dr. Nicole Pristera (Cleveland Clinic cardiology fellow). Flutter moment by student doctor Arooma Shahid.
On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more.
CardioNerds Myocarditis PageCardioNerds Multimodality CV Imaging PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll
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Links in this episode:
Mental Filter: Matters of the Heart: Part 1Mental Filter: Matters of the Heart: Part 2Cardiac Imaging Agorà
Dr. Debbie Kwon attended medical school at the University of Michigan and internal medicine residency at the University of Pennsylvania. She completed her general cardiology and cardiovascular imaging fellowships at the Cleveland Clinic. She is the Director of Cardiac MRI At the Cleveland Clinic and serves as the Core Lab MRI director for the Pulmonary Vascular Disease Phenomics (PVDOMICS) multicenter National institution of Health (NIH) Study.
Dr. Nicole Pristera is a cardiology fellow at the Cleveland Clinic. She earned her medical degree at Case Western Reserve University and completed her internal medicine residency training at Duke University. Her clinical interests include interventional cardiology and cardiac critical care. Outside of the hospital, she enjoys traveling, hiking, and learning foreign languages.
Dr. Arooma Tahir completed her medical degree from Lahore Medical and Dental college in Lahore Pakistan. She went to medical school to pursue her passion and currently she is studying for USMLEs in Fresno, CA. She enjoys hiking, trying out different cuisines, and podcast by cardionerds.
Interview Questions
How would you give a basic intro to cardiac MRI principles to a first year cardiology fellow? What should we know about the common sequences for cardiac MRI?We all learn about the risks of NSF. How much of these risks are a reality and when should we truly avoid gadolinium exposure?What are some challenges to MRI?What types of information about the heart can we obtain with a CMR?
The role for Cardiac MRI in particular cases discussed with Dr. Kwon
CAD: A 45 year old G1P1 woman with prior preeclampsia and anterior STEMI s/p LAD PCI 3 years ago is being seen for chest pain. TTE shows LVEF 45% with mid-apical anterior hypokinesis and apical aneurysm. How does CMR help delineate ischemic heart disease (perfusion, viability, chambers)
Pericarditis: her stress MRI shows an anteroapical perfusion defect and apical aneurysm with mural thrombus, with corresponding LGE. On further review, her chest pain is sharp, pleuritic, and worsens with recumbency. EKG on follow-up shows diffuse ST elevations and PR depressions except for in aVR which shows ST depression and PR elevation. ESR and CRP are moderately elevated.
ARVC: A 35 year old female athlete who is admitted after VF arrest that occurred during a tennis match. Thankfully she received immediate bystander CPR with early defibrillation and prompt ROSC. She has had prior syncope during training and an uncle died suddenly at age 40. Resting EKG shows an incomplete right bundle, right precordial TWIs, and epsilon waves in V1-V3. On tele she’s had multiple runs of NSVT of LBBB morphology. Echocardiogram shows RV dilation. A heart failure consult is considering EMBx but requests a CMR beforehand. Role in select other cardiomyopathies: HCM, Amyloid, hemochromatosis etc (if time)
Valvular Heart Disease: A 28 year old man with no PMH who presents...
32. Patient Perspective of Fulminant Myocarditis with Cardiogenic Shock
May 17, 2020
What does it feel like to have fulminant myocarditis? How does it feel to see a loved one on ECMO? What impact do healthcare heroes have on their patients' and their families'? Tune into this remarkable firsthand patient perspective as Chas and Julie Miller recount their experience with fulminant myocarditis. In Episode 31 we discussed the science & medicine of myocarditis. Now in Episode 32 we realize the emotions and human experience on the other side through the lens of a patient and his loving wife. Special messages from CCU nursing, Megan VanName, Alyssa Noonan, and Kelly Norsworthy, as well as Dr. Dan Choi, cardiac surgeon at Johns Hopkins Hospital.
On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more.
Take me to the Myocarditis Series PageTake me to the episode topics pagesCheck out Amit Goyal’s Myocarditis Tweetorial
5 points of maximal impulse in approaching myocarditis (review from episode 31)
Build the clinical suspicion for myocarditis: You need a high index of suspicion given the variable presentation, and definitely need to keep a differential so you don’t miss things like acute coronary syndromes.Decide if EMBx is necessary: Most often obtained in fulminant presentations to look for pathologic findings of giant cell myocarditis or eosinophilic myocarditis, because these findings will change management.Manage the acute cardiac injury, which can range from supportive care to treatment of shock, arrhythmias, and even tamponade.Manage the chronic cardiac sequelae: Recovering from the acute phase of myocarditis doesn’t necessarily mean smooth sailing — some develop chronic heart failure, warranting GDMT — or guideline directed management and therapy, as defined byDr. Randall Starling in Ep 13.Treat the myocarditis: Immunosuppression is often started empirically in fulminant disease, but continuation depends on what you find on pathology.
31. Fulminant Myocarditis with Cardiogenic Shock: Case Discussion
May 11, 2020
The CardioNerds discuss a case of fulminant myocarditis, teaching a comprehensive approach to myocarditis with just 5 foundational principles. Review the myocarditis infographic on the myocarditis topic page. The episode ends with a special message from the true heroes of this episode, Chas and Julie Miller.
This marks our first episode after 100,000 downloads of the show - and this is a benchmark that we are celebrating together with all of you. Since launch, we have had 82 voices on the show and youtube channel. Our website which collates all the podcast episodes, youtube videos, tweetorials, and more has been accessed in 120 countries. We just cannot thank you enough!
On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more.
Take me to the Myocarditis Series PageTake me to the episode topics pagesCheck out Amit Goyal's Myocarditis Tweetorial
5 points of maximal impulse in approaching myocarditis
Build the clinical suspicion for myocarditis: You need a high index of suspicion given the variable presentation, and definitely need to keep a differential so you don’t miss things like acute coronary syndromes.Decide if EMBx is necessary: Most often obtained in fulminant presentations to look for pathologic findings of giant cell myocarditis or eosinophilic myocarditis, because these findings will change management.Manage the acute cardiac injury, which can range from supportive care to treatment of shock, arrhythmias, and even tamponade.Manage the chronic cardiac sequelae: Recovering from the acute phase of myocarditis doesn’t necessarily mean smooth sailing -- some develop chronic heart failure, warranting GDMT -- or guideline directed management and therapy, as defined by Dr. Randall Starling in Ep 13.Treat the myocarditis: Immunosuppression is often started empirically in fulminant disease, but continuation depends on what you find on pathology.
30. Myocarditis with Drs. JoAnn Lindenfeld, Javid Moslehi and Dr. Enrico Ammirati: Part 2
May 03, 2020
Cardiovascular experts, Drs. JoAnn Lindenfeld, Javid Moslehi and Richa Gupta from Vanderbilt University Medical Center and Dr. Enrico Ammirati from Milan, Italy join Amit and Dan for a two part discussion about all things to consider for myocarditis in general (part 1) and COVID-19 myocarditis and heart transplantation in the COVID-19 era (part 2). Flutter Moment by Barrie Stanton (RN).
On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more.
Take me to the Myocarditis Series Page
Take me to the COVID-19 Series Page
Take me to the Episode Topics Page
Dr. JoAnn Lindenfeld, is a Professor of Medicine and the Director of Heart Failure and Heart Transplantation Section at Vanderbilt Heart and Vascular Institute. She is the past president of the Heart Failure Society of America and serves on editorial boards of numerous journals including JACC, JACC Heart Failure and JHLT. She is also a member of the AHA/ACC/HFSA heart failure guideline writing committee and was previously chair of the HFSA practice guidelines for the 2006 and 2010 guidelines. In addition to this she’s been an investigator in multiple large-scale clinical trials including the COAPT trial and has served on numerous steering committees, end point committees and data and safety monitoring committees. She is the author of a more than 300 original papers, reviews, and book chapters in the field of heart failure and heart transplantation.
Dr. Javid Moslehi is an associate professor of medicine at Vanderbilt University Medical Center where he is the director of the cardio-oncology program. He is a clinical cardiologist and basic/translational biologist interested in cardiovascular complications associated with novel molecular targeted cancer therapies and the implications of these on our knowledge of basic cardiovascular biology. At Vanderbilt he runs an independent basic and translational research laboratory and program with a focus on signal transduction in the myocardium and vasculature as well as establishing pre-clinical models of cardiotoxicity involving novel targeted oncologic therapies.
Dr. Enrico Ammirati is an assistant professor of cardiology and advanced heart failure and transplant cardiologist in Milan, Italy at the Niguarda Hospital with a special research interest and expertise in acute myocarditis and acute heart failure. He is a fellow of the European Society of Cardiology and has won numerous awards, he has also published incredibly important work on the distinction between fulminant and nonfulminant myocarditis and the prognostic implication of histologic subtypes. His research interests also include the role of adaptive immunity in heart transplantation and atherosclerosis and he is the author of well over 100+ peer reviewed publications.
29. Myocarditis with Drs. JoAnn Lindenfeld, Javid Moslehi and Dr. Enrico Ammirati: Part 1
Apr 27, 2020
Cardiovascular experts, Drs. JoAnn Lindenfeld, Javid Moslehi and Richa Gupta from Vanderbilt University Medical Center and Dr. Enrico Ammirati from Milan, Italy join Amit and Dan for a two part discussion about all things to consider for myocarditis in general (part 1) and COVID-19 myocarditis and heart transplantation in the COVID-19 era (part 2). Flutter Moment/Song by Drs. Matt (Internal Medicine) and Beth Faiman (Oncology).
On the CardioNerds Myocarditis page you will find podcast episodes, infographic, youtube videos, references, tweetorials and guest experts & contributors, flutter stars and so much more.
Take me to the Myocarditis Series Page Take me to the COVID-19 Series PageTake me to the Episode Topics Page
Interview Questions
What is myocarditis?How do we classify it?How do we diagnose myocarditis?Why don’t we biopsy everyone?When do we think biopsy may change management?Do we really understand the mechanism of myocardial injury in what we call myocarditis?How do we figure mechanisms out and why is this important?
Guests and Experts
Dr. JoAnn Lindenfeld, is a Professor of Medicine and the Director of Heart Failure and Heart Transplantation Section at Vanderbilt Heart and Vascular Institute. She is the past president of the Heart Failure Society of America and serves on editorial boards of numerous journals including JACC, JACC Heart Failure and JHLT. She is also a member of the AHA/ACC/HFSA heart failure guideline writing committee and was previously chair of the HFSA practice guidelines for the 2006 and 2010 guidelines. In addition to this she’s been an investigator in multiple large-scale clinical trials including the COAPT trial and has served on numerous steering committees, end point committees and data and safety monitoring committees. She is the author of a more than 300 original papers, reviews, and book chapters in the field of heart failure and heart transplantation.
Dr. Javid Moslehi is an associate professor of medicine at Vanderbilt University Medical Center where he is the director of the cardio-oncology program. He is a clinical cardiologist and basic/translational biologist interested in cardiovascular complications associated with novel molecular targeted cancer therapies and the implications of these on our knowledge of basic cardiovascular biology. At Vanderbilt he runs an independent basic and translational research laboratory and program with a focus on signal transduction in the myocardium and vasculature as well as establishing pre-clinical models of cardiotoxicity involving novel targeted oncologic therapies.
Dr. Enrico Ammirati is an assistant professor of cardiology and advanced heart failure and transplant cardiologist in Milan, Italy at the Niguarda Hospital with a special research interest and expertise in acute myocarditis and acute heart failure. He is a fellow of the European Society of Cardiology and has won numerous awards, he has also published incredibly important work on the distinction between fulminant and nonfulminant myocarditis and the prognostic implication of histologic subtypes. His research interests also include the role of adaptive immunity in heart transplantation and atherosclerosis and he is the author of well over 100+ peer reviewed publications.
JoAnn Lindenfeld, MDEnrico Ammirati, MDJavid Moslehi, MDMyocarditis Infographic
28. Influenza and Myocardial Infarction with Drs. Steven Schulman and Rhanderson Cardoso
Apr 19, 2020
In the midst of the COVID-19 pandemic, we take a look at the association between influenza and myocardial infarction with Dr. Steven Schulman, director of the coronary care unit and cardiology fellowship program director at The Johns Hopkins Hospital and Dr. Rhanderson Cardoso, cardiology fellow at the Johns Hopkins Hospital. Flutter moment by Euri Perio (RN).
In light of the COVID-19 pandemic, we shifted gears to meet the educational need as we all are learning more about the cardiovascular implications of SARS-CoV-2. On the CardioNerds COVID-19 series page, you will find our collection of podcast episodes, infographic, youtube videos, curated #Tweetorials, references, guest experts & contributors, flutter stars and so much more.
Check out the COVID-19 series page!Take me to episode topics pageClick here for Youtube COVID-19 PlaylistClick here for our Youtube CV fundamentals playlistYoutube video on QTc measurement
Dr. Steven Schulman graduated from Johns Hopkins University School of Medicine. He fulfilled his training in internal medicine and chief residency, as well as completing his cardiology fellowship at Hopkins. Dr. Schulman is the director of the Coronary Care Unit (CCU) as well as the Cardiology Fellowship Program Director at Johns Hopkins. His main research interests include acute myocardial infarction. He has won numerous teaching awards from Hopkins residents and fellows over the years. While attending the CCU, Dr. Schulman teaches and guides the next generation of residents and fellows about acute cardiac care.
Dr. Rhanderson Cardoso graduated from medical school at the University of Goias in his home country Brazil. He then completed Internal Medicine residency and a chief year at the University of Miami-Jackson Memorial Hospital. Rhanderson has diverse interests in cardiovascular diseases, including electrophysiology, imaging, and prevention. He is especially passionate about teaching and hopes to have a career in academic medicine. He is currently earning a Masters degree in Cardiovascular Epidemiology at the Hopkins Bloomberg School of Public health and is planning on pursuing additional imaging training at Brigham and Women’s Hospital in the upcoming academic year.
27. COVID-19: ID Part 4: Virology and epidemiology with Drs. Chida and Nematollahi
Apr 12, 2020
Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this final episode, we discuss the virology and epidemiology of SARS-CoV-2 that serves as the underpinnings for the three prior episodes. Flutter Moment by Dr. Sumeet Bahl (Vascular and Interventional Radiology)
We are honored to promote the incredible efforts of #GetUsPPE, a nonprofit organization working hard to make sure every healthcare worker is protected. Dr. Seth Trueger, emergency medicine physician and digital media editor @JAMA Network Open shares an earnest request.
In light of the COVID-19 pandemic, we shifted gears to meet the educational need as we all are learning more about the cardiovascular implications of SARS-CoV-2. On the CardioNerds COVID-19 series page, you will find our collection of podcast episodes, infographic, youtube videos, curated #Tweetorials, references, guest experts & contributors, flutter stars and so much more.
Check out the COVID-19 series page!
Take me to episode topics page
Click here for Youtube COVID-19 Playlist
Click here for our Youtube CV fundamentals playlist
Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees -- she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.
Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education. More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.
26. COVID-19: ID Part 3: Presentation and diagnosis with Drs. Chida and Nematollahi
Apr 06, 2020
Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this third episode, we discuss all things to consider with regards the clinical presentation & diagnosis of COVID-19. Be sure to stay tuned for the remaining part of this mini-series where we will the virology of SARS-CoV-2. Flutter Moment by Dr. Dani Dumitriu from the frontlines of the COVID-19 pandemic in NYC.
We are honored to promote the incredible efforts of #GetUsPPE, a nonprofit organization working hard to make sure every healthcare worker is protected. Dr. Michelle Myles, emergency medicine physician shares her PPE story.
In light of the COVID-19 pandemic, we shifted gears to meet the educational need as we all are learning more about the cardiovascular implications of SARS-CoV-2. On the CardioNerds COVID-19 series page, you will find our collection of podcast episodes, infographic, youtube videos, curated #Tweetorials, references, guest experts & contributors, flutter stars and so much more.
Check out the COVID-19 series page!
Take me to episode topics page
Click here for Youtube COVID-19 Playlist
Click here for our Youtube CV fundamentals playlist
Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees -- she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.
Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education. More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.
25. COVID-19: ID Part 2: Protecting Healthcare Workers with Drs. Chida and Nematollahi
Apr 02, 2020
Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this second episode, we discuss all things to consider with regards to protecting healthcare workers in COVID-19 as well as their families as they face the pandemic. Be sure to stay tuned for the remaining 2 parts of this mini-series where we will discuss the clinical presentation and diagnosis of COVID-19, and the virology. Flutter Moment by Dr. Meredith Sloan (Internal medicine, University of Mississippi Medical Center).
Check out the COVID-19 series page!
Take me to episode topics page
Click here for Youtube COVID-19 Playlist
Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees -- she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.
Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education. More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.
Besides for discussing Protecting Healthcare Workers in COVID-19, we are thrilled to have Dr. Meridith Sloan on the Cardionerds podcast for her inspiring flutter moment!
Dr. Meredith Sloan is a proud graduate of the University of Virginia (Wahoowa!) and went to the Medical University of South Carolina. She is currently a third year Internal Medicine resident at the University of Mississippi Medical Center, and is looking forward to being a Chief Resident next year.
24. COVID-19: ID Part 1: Emerging treatments with Drs. Chida and Nematollahi
Mar 30, 2020
Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this first part we discuss the emerging therapies in our armamentarium. Be sure to stay tuned for the remaining 3 parts in which we tackle advice for the health care worker, the clinical presentation & diagnosis, and the virology. Flutter Moment by Dr. Justin Berk (Medicine/Pediatrics).
Check out the COVID-19 series page!
Take me to episode topics page
Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees -- she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.
Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education. More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.
23. COVID-19: The experience of an ICU doctor who also became a patient with Dr. Dan Grove
Mar 27, 2020
Dr. Dan Grove is a critical care physician who was diagnosed with COVID-19. Join us as we discuss Dr. Grove’s personal journey and reflections while transitioning from physician to patient, the etymology of the word quarantine, tips and tricks to keep family members safe while in self isolation, and a message to our brothers and sisters on the frontlines as well as the general public. Flutter Moment by Dr. Dani Dumitriu (Pediatrics, Neuroscientist and Pediatric environmental health science)
Check out the COVID-19 series page!
Take me to episode topics page
Follow Dr. Grove’s personal Covid-19 Journey
Dr. Daniel Grove serves as assistant director of critical care at Medstar Union Memorial Hospital. He earned his medical degree at Emory University School of Medicine where he also completed his residency and fellowship training in internal medicine and pulmonary and critical care medicine. Dr. Grove is a physician leader in his community and is involved in patient advocacy on many levels.
Dan Grove, MD
22. COVID-19: The Iranian Experience with Dr. Reza Hashemian
Mar 25, 2020
We share with you the Iranian experience with COVID-19, a rare first hand report from ICU doctor, Dr. Reza Hashemian, covering the clinical, the societal, and the personal. Flutter Moment by Edward Nejat (Reproductive Endocrinology).
Check out the COVID-19 series page!
Take me to episode topics page
Ventilation primer for the cardiologist (Youtube)
Dr. Reza Hashemian serves as Professor of Critical care medicine at a large academic hospital in the heart of Iran. He in on the frontlines at Masih Daneshvari hospital in Tehran, the country’s top pulmonary public hospital and the main facility overseeing coronavirus patients.
21. COVID-19: The Italian Experience with Dr. Gianluca Pontone
Mar 22, 2020
Tune in to hear the Italian perspective from a “COVID A” cardiovascular hospital in Milan, the heart of the country’s epidemic shared by Dr. Gianluca Pontone, who serves as Director of Cardiovascular Imaging Department Centro Cardiologico Monzino IRCCS, University of Milan. We discuss management of COVID-19 patients with underlying cardiovascular disease and cardiac manifestations of COVID-19 including acute coronary syndromes, cardiogenic shock, and myocarditis. Dr. Pontone shares his personal experience in terms of how he prepares himself to take care of patients during this time and his message for all CardioNerds to hear. Flutter Moment by Nino Isakadze (Cardiology).
Check out the COVID-19 series page!
Take me to episode topics page
Ventilation primer for the cardiologist (Youtube)
Dr. Gianluca Pontone serves as Director of Cardiovascular Imaging Department Centro Cardiologico Monzino IRCCS, University of Milan, Italy. He graduated with honors in medicine in 1997 followed by post-graduate degree in cardiology and radiology at University of Milan in 2001 and 2006 respectively. He is currently in the board of directors of Society of Cardiovascular Computed Tomography (SCCT), chairman of CT certification committee of European Association of Cardiovascular Imaging (EACVI) and chairman of working group of cardiac magnetic resonance of Italian society of cardiology.
20. COVID-19 in the ICU – Approach to cardiopulmonary support
Mar 20, 2020
COVID-19 in the ICU: The CardioNerds follow the case of Sara S Covids through her journey with COVID-19 complicated by progressive respiratory failure. Learn how critical care physicians, Drs. David Furfaro and Sam Brusca approach cardiopulmonary mechanics, general ventilator settings, ventilation in patients with cardiac disease, ARDS diagnosis and management algorithms, including VV and VA ECMO support considerations. Importantly, we discuss these issues in the context of the COVID-19 era and how applies to the safety of the healthcare worker and appropriate use of personal protective equipment with a particular emphasis on COVID-19 in the ICU. Both physicians share tips and tricks on coping and staying motivated as they face this crisis.
This episode is broadly applicable for anyone taking care of patients with cardiopulmonary disease. In the COVID era, this is every provider. Flutter Moment by Emily (Pediatric RN)
Check out the COVID-19 series page!
Take me to episode topics page
Ventilation primer for the cardiologist (Youtube)
Dr. Samuel Brusca received his medical degree from New York University School of Medicine. He went on to complete his internal medicine training in the Osler Residency Program at Johns Hopkins Hospital and is currently a research fellow in the Critical Care Medicine Fellowship at the National Institutes of Health. His current interests include critical care cardiology, pulmonary arterial hypertension, and right ventricular failure. He is thrilled to be joining the Cardiovascular Disease Fellowship at UCSF this coming July. Outside the hospital, Sam and his amazing wife, Becky, were recently joined by their first daughter, the adorable Madeleine.
Dr. David Furfaro received a degree in chemistry with a minor in pharmacology from Duke University. After college, he volunteered with Americorps for a year working with patients with HIV. He received his MD from Harvard Medical School. From there he completed his internal medicine training in the Osler Residency at Johns Hopkins. He returned to Johns Hopkins as an Assistant Chief of Service. He is currently a Pulmonary and Critical Care Medicine Fellow at Columbia University Medical Center. He is interested in critical care, pulmonary hypertension, and lung transplantation. He is also a dedicated medical educator and a huge Cardio Nerds fan!
19. COVID-19 interactions with ACE-I and ARBS with Dr. Oscar Cingolani
Mar 17, 2020
The CardioNerds explore the cardiovascular implications of COVID-19 caused by the SARS-CoV 2, in patients with and without underlying cardiovascular disease. We discuss a range of important topics such as ACE-I and ARBS and COVID-19, a 4 part ID mini-series on SARs-CoV 2, important perspectives from clinicians on the frontlines of Italy and Iran, a primer on ICU care for COVID-19 positive patients and so much more!
The series kicks off with Dr. Oscar Cingolani, Director of the Hypertension Center at the Johns Hopkins Hospital is joined by Drs. Amit Goyal, Carine Hamo, and Daniel Ambinder and discuss what is known about the interplay between ACE-I and ARBS and COVID-19. We also learn tips and tricks from Dr. Cigolani's experience with telemedicine use with the hypertension clinic. Flutter Moment by Dr. Stephen Lockey (Orthopedic Surgery)
Check out the COVID-19 series page!
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Dr. Oscar Cingolani earned his medical degree from the National University of La Plata, Argentina, and completed his Internship and Internal Medicine Residency at CEMIC, Buenos Aires, Argentina, and hypertension research post-doctoral fellowship at Henry Ford Hospital, Detroit, Michigan. After completing his Internal Medicine Residency at The Reading Hospital and Medical Center in Pennsylvania, Dr. Cingolani joined The Johns Hopkins Hospital as a Cardiology fellow, where he remained on Faculty after his training. He is currently the Associate Director of The Johns Hopkins Hospital Cardiac Care Unit and the Director of the Hypertension Center. Dr. Cingolani’s research interests focus on hypertensive heart disease and its transition to heart failure.
Dr. Stephen Lockey graduated from Georgetown University School of Medicine and obtained an MBA from the McDonough School of Business. He is currently a third-year resident in Orthopaedic Surgery at Georgetown University Hospital. He is interested in pursuing additional training in spine surgery.
18. Women’s Cardiovascular Health with Dr. Martha Gulati
Mar 08, 2020
Best-selling author Dr. Martha Gulati joins the CardioNerds squad, Carine Hamo, Heather Kagan, Amit Goyal, and Daniel Ambinder for an unbelievable discussion on women's cardiovascular health relevant to anyone taking care of women. Topics discussed include disparities in diagnosis, treatment, and outcomes in women vs men, sex specific risk factors for cardiovascular disease, special considerations for the evaluation of women presenting with chest pain, and cardiac conditions that have a female predominance, how to be a trailblazer in cardiovascular medicine and so much more!
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Dr. Martha Gulati completed medical school at the University of Toronto, Canada and her internship, residency and cardiology fellowship at the University of Chicago. She previously served as the Sarah Ross Soter Chair in Women’s Cardiovascular Health and the section director for Women’s Cardiovascular Health and Preventive Cardiology at Ohio State University. She currently serves as division chief of Cardiology for the UA College of Medicine – Phoenix. She is also editor-in-chief of ACC’s CardioSmart.
Dr. Gulati has made incredible contributions to researching cardiovascular disease in women. She is the principal investigator of the St. James Women Take Heart Project, a co-investigator on the Women Ischemic Syndrome Evaluation (WISE); previously served as a co-investigator on the Women’s Health Initiative (WHI); a member of numerous advisory boards and societies, including the American Heart Association and the American College of Cardiology; and has published articles in The New England Journal of Medicine, Circulation and Journal of the American Medical Association (JAMA). She is also the best-selling author of Saving Women’s Hearts!
References
Gulati, M., & Merz, C. (2016). Advances in Lipid Therapy: The Role of Lipid Treatment in Women in Primary Prevention. Progress in Cardiovascular Diseases.Gulati, M. (2017). Improving the Cardiovascular Health of Women in the Nation: Moving beyond the Bikini Boundaries. Circulation, 135(6), 495-498. Lippincott Williams and Wilkins.Wenger NK (2005) Women in cardiology: The US experience. Heart.Douglas PS, Rzeszut AK, Noel Bairey Merz C, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L (2018) Career preferences and perceptions of cardiology among us internal medicine trainees factors influencing cardiology career choice. JAMA Cardiol.Wenger NK, Speroff L, Packard B (1993) Cardiovascular Health and Disease in Women. N Engl J Med.Burgess S, Shaw E, Zaman S (2019) Women in Cardiology. Circulation.
17. HF part 6: Atrial Fibrillation and Heart Failure with Dr. Jonathan Piccini
Mar 01, 2020
Duke cardiology fellow, Rahul Loungani, interviews Dr. Jonathan Piccini, director of the Electrophysiology Clinical Trials Program and Arrhythmia Core Laboratory at Duke University, about atrial fibrillation management in patients with heart failure. They discuss rate vs rhythm control and strategies for both, new onset AF in the context of critical illness, wearable devices in AF, escalation of therapy in AF, ideal patient for catheter ablation, and AF patients with cardiac resynchronization therapy.
On the CardioNerds Heart Failure topic page you’ll podcast episodes, references, guest experts and contributors, and so much more.
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Acute Decompensated Heart Failure Primer – Youtube
Jonathan P. Piccini, MD, MHS is a clinical cardiac electrophysiologist and Associate Professor of Medicine at Duke University Medical Center and the Duke Clinical Research Institute. His research interests include the conduct of clinical trials and the assessment of cardiovascular therapeutics for the care of patients with heart rhythm disorders. At present, he is the Director of the EP Clinical Trials Program and Arrhythmia Core Laboratory at Duke University. He also serves on the Clinical Working Group of the American Heart Association’s Get With The Guidelines – Atrial fibrillation (GWTG-Afib) registry program. He is an associate editor for the American Heart Journal and serves on the editorial board of Heart Rhythm, the European Heart Journal, and the Journal of Cardiac Electrophysiology. He is the Principal Investigator of the data and coordinating center for ORBIT AF, a 25,000 patient registry focused on quality of care and improving outcomes in patients with atrial fibrillation. He is also the PI of the GENETIC AF clinical trial, the first clinical trial to study genotype-directed rhythm control therapy for atrial fibrillation. He also serves on the steering committees of multiple international randomized trials focused on the treatment of atrial fibrillation. Dr. Piccini has more than 175 publications in the field of heart rhythm medicine. Clinically, his focus is on the care of patients with atrial fibrillation and complex arrhythmias, with particular emphasis on catheter ablation and lead extraction.
Dr. Rahul Loungani completed medical school at the medical university of SC and then traveled to Baltimore for internal medicine training in the Osler Residency Program at the Johns Hopkins Hospital. Here he fell in love with the management and hemodynamics of critically ill patients. He is currently a third-year cardiology fellow at Duke University Medical Center where he will also be pursuing fellowship in advanced heart failure and transplant cardiology next year. His current interests are in Cardiac amyloid, In particular its arrhythmic manifestations, early diagnosis, and novel therapeutics. He also loves teaching the housestaff and was awarded the Cassell-Saperstein award at Duke, recognizing the fellow who most demonstrates a commitment to teaching and passion for clinical education. Outside of the hospital loves being a new dad to baby Arya
16. HF part 5: Heart transplantation 101 with Dr. JoAnn Lindenfeld
Feb 26, 2020
Vanderbilt fellows, Richa Gupta and Jessica Huston, interview past HFSA president Dr. JoAnn Lindenfeld, Director of Heart Failure and Heart Transplantation Section at Vanderbilt Heart and Vascular Institute about the nuts and bolts of cardiac transplantation. Topics discussed include organ allocation, recipient selection, high risk donors, short and long term complications, and what non-transplant physicians should know about immunosuppressive medications.
On the CardioNerds Heart Failure topic page you’ll podcast episodes, references, guest experts and contributors, and so much more.
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Acute Decompensated Heart Failure Primer – Youtube
Dr. JoAnn Lindenfeld, is a Professor of Medicine and the Director of Heart Failure and Heart Transplantation Section at Vanderbilt Heart and Vascular Institute. She is the past president of the Heart Failure Society of America and serves on editorial boards of numerous journals including JACC, JACC Heart Failure and JHLT. She is also a member of the AHA/ACC/HFSA heart failure guideline writing committee and was previously chair of the HFSA practice guidelines for the 2006 and 2010 guidelines. In addition to this she’s been an investigator in multiple large-scale clinical trials including the COAPT trial and has served on numerous steering committees, end point committees and data and safety monitoring committees. She is the author of a more than 300 original papers, reviews, and book chapters in the field of heart failure and heart transplantation.
Dr. Richa Gupta completed medical school at the Johns Hopkins School of Medicine and stayed on for internal medicine training in the Osler Residency Program at the Johns Hopkins Hospital. She is currently a third-year cardiology fellow at Vanderbilt University Medical Center where she will also be pursuing fellowship in advanced heart failure and transplant cardiology next year. Her current interests include post-transplant outcomes, the genetics of tachycardia-induced cardiomyopathy, the sequelae of mechanical circulatory support and applications of cardiac MRI. She also loves teaching the housestaff and medical students and getting them excited about all things heart failure. Outside of the hospital she loves horror movies, food, travel and good exercise.
Dr. Jessica Huston is an Advanced Heart Failure and Cardiac Transplant fellow at Vanderbilt University Medical Center where she also completed her Cardiovascular Medicine fellowship and served as chief fellow. Prior to her time at Vanderbilt she completed residency at the University of Utah. Her clinical and research interests include pulmonary vascular remodeling in heart failure, pulmonary hypertension and right ventricular failure. Outside the hospital she enjoys exploring the outdoors with her son.
15. HF part 4: LVAD 101 with Dr. Steve Hsu
Feb 23, 2020
Carine and Dan delve into left ventricular assist devices (LVAD) 101 with Dr. Steven Hsu, heart failure specialist at the Johns Hopkins Hospital. We get big picture, we get detail oriented and we hit the highlights for the psycho-social-and medical management of our LVAD patient population.
14. HF part 3: Approach to advanced heart failure strategies with Dr. Jerry Estep
Feb 19, 2020
Amit and co-fellow Dr. Kartik Telukuntla discuss advanced heart failure therapies, or salvage therapies, with Dr. Jerry Estep, section head of heart failure at the Cleveland Clinic.
Show page: https://www.cardionerds.com/heart-failure-awareness-cardionerds-series/
Dr. Jerry Estep earned his bachelor of arts at the University of Texas, Austin and subsequently received his medical degree from Baylor College of Medicine. He completed internal medicine residency training at University of Texas Southwestern Medical Center and went back to Baylor for his cardiology and heart failure fellowship training. Prior to joining Cleveland Clinic in 2018 as our section head for the division of heart failure and transplant, Dr. Estep was the Section Head of Heart Failure at Methodist DeBakey in Houston, Texas. Dr. Estep has been involved in numerous clinical trials and co-authored over a 100 peer reviewed articles. He has a special interest in mechanical circulatory support devices and has published heavily on the percutaneous placement of intra-aortic balloon pump in the axillary artery as a long-term support option to bridge patients to transplant.
13. HF part 2: Approach to GDMT with Dr. Randall Starling
Feb 16, 2020
Amit and co-fellow Kartik Telukuntla talk to Dr. Randall Starling, former president of the HSFA about his approach to guideline-directed medical therapy in heart failure.
Dr. Randall Starling obtained his Bachelor’s degree and Master’s in Public Health at the University of Pittsburgh and medical degree from Temple University. He went back to University of Pittsburgh for his internal medicine residency training and then went to Ohio State University for his cardiology fellowship. He stayed on as faculty at Ohio State until 2005 at which time he joined the Cleveland Clinic. He is the former section head of the Division of Heart Failure and former Vice Chairman of the Cardiovascular Medicine Department. Dr. Starling has been the principal investigator on numerous clinical trials and most recently completed his tenure as President of the Heart Failure Society of America.
Show page: https://www.cardionerds.com/heart-failure-awareness-cardionerds-series/
12. HF part 1: Evaluation of new onset heart failure with Dr. Ed Kasper
Feb 13, 2020
Dan and Carine chat with cardiomyopathy expert Dr. Ed Kasper with regards to his approach to the new onset heart failure patient. This episode is dedicated to Dr. Kasper's mentor and friend, Dr. Kenneth L. Baughman.
Dr. Edward K. Kasper, is a graduate of the Johns Hopkins University with a B.A. in Natural Sciences. He earned his M.D. at the University of Connecticut School of Medicine. His internship and residency in Internal Medicine and assistant chief of service (ACS) of the Thayer service as well as his fellowship in Cardiology, were completed at the Johns Hopkins Hospital, where he then joined the faculty in 1993. He is currently the E. Cowles Andrus Professor of Cardiology and Director of Clinical Cardiology at Johns Hopkins Medicine.
Show page: https://www.cardionerds.com/heart-failure-awareness-cardionerds-series/
11. HF part 0: Preamble and tribute to Dr. David Taylor
Feb 12, 2020
In conjunction with the 2020 Heart Failure Awareness Week, sponsored by the Heart Failure Society of America the CardioNerds are supporting the society’s efforts to promote heart failure awareness, patient education, and heart failure prevention by launching our Heart Failure Awareness CardioNerds Series.
This series is a tribute to Dr. David Taylor. Dr. Taylor was a heart failure attending at the Cleveland Clinic. He died early morning of Thursday, February 5th 2020. We remember him for the legend he is. A passionate clinician, skilled educator, devoted mentor.
Series page: https://www.cardionerds.com/heart-failure-awareness-cardionerds-series/
10. AL (Light-Chain) Cardiac Amyloidosis with Dr. Ronald (Ron) Witteles
Feb 09, 2020
Dr. Ron Witteles from Standford university provides an approach to cardiac amyloid and specifically AL (Light-Chain) Cardiac Amyloidosis. The discussion is lead by Amit and Dr. Ashley Bock. This episode is the fourth and final part of our immersive journey into the jungle of beta-pleated sheets in the heart. We focus on AL amyloidosis in this episode. Flutter moment by Lois Adamski.
On the CardioNerds Cardiac Amyloid Topic Page you will find podcast episodes, infographic, references, guest contributors, flutter stars, and so much more.
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Cardiac imaging for Amyloid - Youtube
Dr. Ronald Witteles is a graduate of Northwestern University where he earned his B.A. in Biology, and of the University of Chicago Pritzker School of Medicine, where he earned his M.D. with Honors. He then moved west to Stanford University where he completed IM residency and Cardiology fellowship training, serving as both Chief Resident and Chief Fellow. He subsequently joined the faculty at Stanford, and is currently appointed as Professor of Medicine (Cardiovascular Medicine). He has served as Program Director for the Stanford University Internal Medicine Residency Training Program for more than 10 years, where he leads a residency program of approximately 140 residents. He is Co-Director of the Stanford Amyloid Center – one of the nation’s largest centers in the country which specializes in the treatment of patients with amyloidosis, and he leads an active research program in this area. He also serves as Co-Director of the Stanford Multidisciplinary Sarcoidosis Program, and he is a national leader in Cardio-Oncology, serving as Associate Editor for the country’s premier journal dedicated to the field, JACC: CardioOncology.
Dr. Ashley Bock earned her medical degree at the University of Colorado and completed her internal medicine residency training at Duke University. From there she came to the Cleveland Clinic for general cardiology fellowship and advanced heart failure training. She joins our team today to discuss AL cardiac amyloidosis with Dr. Witelles.
9. Cardiac Amyloid Associated with HFpEF & Cardiac ATTR treatment with Drs. Virginia Hahn & Joban Vaishnav
Feb 02, 2020
Cardionerds (Daniel Ambinder and Carine Hamo) chat with Dr. Virginia Hahn about her work profiling HFpEF patients via endomyocardial biopsy only to find a significant proportion of patients with unsuspected cardiac amyloid. This is followed by a high yield discussion with Dr. Joban Vaishnav about ATTR cardiac amyloid treatment and management options. Flutter moment by David Ambinder (MS IV).
On the CardioNerds Cardiac Amyloid Topic Page you will find podcast episodes, infographic, references, guest contributors, flutter stars, and so much more.
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Dr. Virginia Shalkey Hahn is a fourth-year Cardiology fellow at Johns Hopkins in Baltimore, MD. She earned her medical degree from the Perelman School of Medicine at the University of Pennsylvania, where she stayed for residency. She moved to Johns Hopkins for Cardiology fellowship (after a 1 year hiatus as an ICU hospitalist). During fellowship, she completed 2 years on the NIH T32 Training grant and one year as chief fellow. She feels passionate about translational heart failure research and mothering her 2 young children.
Dr. Joban Vaishnav completed her undergraduate and medical school training at St. Louis University. She has since been at Johns Hopkins for residency, cardiology fellowship, and advanced heart failure fellowship. Her early research pursuits were in heart failure with preserved ejection fraction. From this, and from her advanced heart failure training, she developed a strong clinical interest and research interest in early diagnosis and treatment of cardiac amyloidosis.
In addition to the great discussion on Cardiac Amyloid ATTR treatment, we are excited to have Dan's brother, David, join the Cardionerds cardiology podcast to share a special flutter moment! David Ambinder is a 4th year medical student at the University of Maryland and will be starting urology residency this coming July at Westchester Medical Center. He grew up in New York and graduated from Touro College before heading to Baltimore for medical school. He enjoys spending time with his wife Samantha and 3 lovely children.
Carine Hamo, MDDaniel Ambinder, MD
8. Cardiac Amyloid Imaging & EP Considerations with Drs. Paul Cremer and Eoin Donnellan
Jan 26, 2020
Amit and Dr. Zach Il’Giovine learn about multimodality imaging in amyloid from Dr. Paul Cremer at the Cleveland Clinic. On their way to Dr. Cremer’s office, they run into Dr. Eoin Donnellan and discuss some incredible fellow research related to cardiac amyloid from an electrophysiologic perspective.
Show notes and images: https://www.cardionerds.com/cardiac-amyloid/
7. Cardiac Amyloid part 1: case discussion
Jan 19, 2020
A new case of congestive heart failure due to amyloid cardiomyopathy is presented by Yuxuan Wang and discussed by Carine, Heather, Dan and Amit. Guest oncology star: Jackie Zimmerman. Flutter moment by Mark Heslin.
Show notes and images: https://www.cardionerds.com/cardiac-amyloid/
6. Hypertrophic Cardiomyopathy Surgical & Transcatheter Septal Reduction Therapies with Drs. Amar Krishnaswamy and Per Wierup
Jan 12, 2020
Amit joins Dr. Laura Young to take a pulse check with experts, and learn more about the structural management of obstructive HCM. They discuss the interventional perspective with interventional cardiologist Dr. Amar Krishnaswamy and surgical perspective from cardiothoracic surgeon Dr. Per Wierup. Flutter moment by Crystal Silbak, RN.
Show notes and images: https://www.cardionerds.com/hypertrophic-cardiomyopathy/
5. Hypertrophic Cardiomyopathy Historical Perspective with Dr. Edward Kasper
Jan 05, 2020
Dr. Edward Kasper shares a unique historical perspective on how the field evolved as medicine learned more about HCM. He shares so many life lessons and clinical pearls that apply to HCM and the practice of medicine in general. Flutter moment by Dr. Sidney Schechet (ophthalmology).
Show notes and images:
https://www.cardionerds.com/hypertrophic-cardiomyopathy/
4. Practical Approach to Hypertrophic Cardiomyopathy with Dr. Jose Madrazo
Dec 29, 2019
Clinical and echo expert Dr. Jose Madrazo discusses a high yield and practical approach to diagnosis and management of hypertrophic cardiomyopathy.
Show notes and images:
https://www.cardionerds.com/hypertrophic-cardiomyopathy/
3. Hypertrophic Cardiomyopathy: Case Discussion
Dec 13, 2019
Dr. Fatimah Alkhunaizi and the CardioNerds discuss a case of hypertrophic cardiomyopathy, covering pathophysiology, diagnosis, imaging, and management of HCM.
Show notes and images:
https://www.cardionerds.com/hypertrophic-cardiomyopathy/
2. Imaging and TAVR for Aortic Stenosis with Drs. Sneha Vakamudi and Rani Hasan
Dec 11, 2019
Amit, Carine, and Dan interview imaging expert Dr. Sneha Vakamudi and structural heart disease expert Dr. Rani Hasan about nuances regarding the diagnosis and treatment of aortic stenosis.
Show notes and images:
https://www.cardionerds.com/episodes/aortic-stenosis/
1. Aortic Stenosis: Case Discussion
Dec 11, 2019
Dr. Heather Kagan and the CardioNerds discuss a case of aortic stenosis, covering diagnosis, surveillance, imaging, management and followup.
Show notes and images:
https://www.cardionerds.com/episodes/aortic-stenosis/
0. Introducing The CardioNerds
Dec 09, 2019
Amit, Dan, and Clinical Problem Solver host Reza Manesh introduce The CardioNerds podcast and the CardioNerd mission.
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